Provider Demographics
NPI:1174515894
Name:OLYMPIC SPORTS & MANUAL THERAPY
Entity type:Organization
Organization Name:OLYMPIC SPORTS & MANUAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:360-452-7798
Mailing Address - Street 1:1607 E FRONT ST
Mailing Address - Street 2:STE C
Mailing Address - City:PT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4636
Mailing Address - Country:US
Mailing Address - Phone:360-452-7798
Mailing Address - Fax:360-452-2772
Practice Address - Street 1:1607 E FRONT ST
Practice Address - Street 2:STE C
Practice Address - City:PT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4636
Practice Address - Country:US
Practice Address - Phone:360-452-7798
Practice Address - Fax:360-452-2772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0151611OtherL & I
8809341Medicare ID - Type Unspecified