1811945900 NPI number — KITSAP PHYSICAL THERAPY LLC

Table of content: DR. ROSE ELLEN SHULTZ BOYD D.C. (NPI 1366637092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811945900 NPI number — KITSAP PHYSICAL THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KITSAP PHYSICAL THERAPY 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:
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:
1811945900
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1880 POTTERY AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PORT ORCHARD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98366-2518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-895-9090
Provider Business Mailing Address Fax Number:
360-895-9089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1880 POTTERY AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-2518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-895-9090
Provider Business Practice Location Address Fax Number:
360-895-9089
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-895-9090

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  602080097 , 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: 0150495 . This is a "WA STATE DEPT OF LABOR IN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: DB8089 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7105166 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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