1912022658 NPI number — MOSES LAKE SPORTS PHYSICAL THERAPY, PS

Table of content: (NPI 1912022658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912022658 NPI number — MOSES LAKE SPORTS PHYSICAL THERAPY, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOSES LAKE SPORTS PHYSICAL THERAPY, PS
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:
1912022658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 N STRATFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOSES LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98837-1572
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-766-4277
Provider Business Mailing Address Fax Number:
509-766-4280

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 N STRATFORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-1572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-766-4277
Provider Business Practice Location Address Fax Number:
509-766-4280
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRUCE
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
509-766-4277

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00005408 , 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: 7062011 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 193527700 . This is a "OWCP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 51945 . This is a "WORK HARDENING" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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