Basic Information
| Provider Information | |||||||||
| NPI: | 1144543323 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUTPATIENT PHYSICAL THERAPY & SPORTS REHABILITATION,INC, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26837 MAPLE VALLEY HIGHWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MAPLE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980389917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254134427 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8009 S 180TH STE | ||||||||
| Address2: | 112 | ||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980321042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252267827 | ||||||||
| FaxNumber: | 4252515757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2010 | ||||||||
| LastUpdateDate: | 10/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL AND FACILITY MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4254134427 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | GAB11700 | 01 | WA | MEDICARE PTAN | OTHER | 7086606 | 05 | WA | MEDICAID |