1962438424 NPI number — FISHERS LANDING PHYSICAL THERAPY

Table of content: (NPI 1962438424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962438424 NPI number — FISHERS LANDING PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FISHERS LANDING PHYSICAL THERAPY
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:
1962438424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 493396
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDDING
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96049-3396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-221-9952
Provider Business Mailing Address Fax Number:
530-221-9954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 SE 164TH AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98683-1107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-882-6997
Provider Business Practice Location Address Fax Number:
360-882-4132
Provider Enumeration Date:
06/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAAS
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
ROY
Authorized Official Title or Position:
CO-OWNER PHYSICAL THERAPIST
Authorized Official Telephone Number:
530-221-9952

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  17866 , 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: 7115371 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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