1437159449 NPI number — RENTON SPORTS & SPINE PT

Table of content: (NPI 1437159449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437159449 NPI number — RENTON SPORTS & SPINE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENTON SPORTS & SPINE PT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437159449
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4361 TALBOT RD S
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98055-6226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-917-9885
Provider Business Mailing Address Fax Number:
425-917-2334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4361 TALBOT RD S
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98055-6226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-917-9885
Provider Business Practice Location Address Fax Number:
425-917-2334
Provider Enumeration Date:
08/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PHYSICAL THERAPIST/CLINIC
Authorized Official Telephone Number:
425-917-9885

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00009406 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0165699 . This is a "DEPT OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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