Provider Demographics
NPI:1174523054
Name:NORTHWEST PHYSICAL THERAPY SPORTS REHABILITATION CENTER, INC., P.S.
Entity type:Organization
Organization Name:NORTHWEST PHYSICAL THERAPY SPORTS REHABILITATION CENTER, INC., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:K
Authorized Official - Last Name:NIHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-428-2700
Mailing Address - Street 1:110 N LAVENTURE RD
Mailing Address - Street 2:STE A
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-3901
Mailing Address - Country:US
Mailing Address - Phone:360-428-2700
Mailing Address - Fax:360-428-2701
Practice Address - Street 1:110 N LAVENTURE RD
Practice Address - Street 2:STE A
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-3901
Practice Address - Country:US
Practice Address - Phone:360-428-2700
Practice Address - Fax:360-428-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600377134225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7155104Medicaid
WACF8029OtherRAILROAD MEDICARE
WAGAB07032Medicare PIN