1700108289 NPI number — OUTPATIENT PHYSICAL THERAPY & SPORTS REHABILITATION INC PC

Table of content: (NPI 1700108289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700108289 NPI number — OUTPATIENT PHYSICAL THERAPY & SPORTS REHABILITATION INC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUTPATIENT PHYSICAL THERAPY & SPORTS REHABILITATION INC PC
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:
1700108289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26837 MAPLE VALLEY BLACK DIAMOND RD SE
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
MAPLE VALLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98038-9917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-413-4427
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27005 168TH PL SE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98042-4902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-639-4788
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
STEELE
Authorized Official First Name:
DAN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
425-413-4427

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GAB11700 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7086606 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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