1588806848 NPI number — LAKE FOREST PARK PHYSICAL THERAPY, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588806848 NPI number — LAKE FOREST PARK PHYSICAL THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE FOREST PARK PHYSICAL THERAPY, PLLC
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:
6
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:
1588806848
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20011 BALLINGER WAY NE
Provider Second Line Business Mailing Address:
STE C100
Provider Business Mailing Address City Name:
SHORELINE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98155-1286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-367-6069
Provider Business Mailing Address Fax Number:
206-367-6319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20011 BALLINGER WAY NE
Provider Second Line Business Practice Location Address:
STE C100
Provider Business Practice Location Address City Name:
SHORELINE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98155-1286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-367-6069
Provider Business Practice Location Address Fax Number:
206-367-6319
Provider Enumeration Date:
04/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WHITEHEAD
Authorized Official First Name:
ROBYN
Authorized Official Middle Name:
NAMIKO
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
206-979-8248

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  PT00002011 , 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: 8371353 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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