Basic Information
| Provider Information | |||||||||
| NPI: | 1205903390 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST CAMPUS SPORT & ORTHOPEDIC PHYSICAL PS INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST STE 140 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980035946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538746620 | ||||||||
| FaxNumber: | 2538742542 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S 336TH ST STE 140 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538746620 | ||||||||
| FaxNumber: | 2538742542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2538746620 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00002979 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8346322 | 05 | WA | MEDICAID | 09521 | 01 | WA | L&I | OTHER |