1740382050 NPI number — MOUNTAIN PHYSICAL THERAPY AND SPORTS REHABILITATION LLC

Table of content: (NPI 1740382050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740382050 NPI number — MOUNTAIN PHYSICAL THERAPY AND SPORTS REHABILITATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN PHYSICAL THERAPY AND SPORTS REHABILITATION LLC
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:
1740382050
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:
PO BOX 1837
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EATONVILLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98328-1837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-832-8890
Provider Business Mailing Address Fax Number:
360-832-8893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
313 CENTER STREET EAST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
EATONVILLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-832-8890
Provider Business Practice Location Address Fax Number:
360-832-8893
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PERRAS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
360-832-8890

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  PT00003700 , 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: 7120846 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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