Basic Information
| Provider Information | |||||||||
| NPI: | 1376607333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PT NORTHWEST OF LONGVIEW INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 3RD AVE | ||||||||
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| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986323229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604239535 | ||||||||
| FaxNumber: | 3604149284 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 COLUMBIA ST STE C | ||||||||
| Address2: | |||||||||
| City: | WOODLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986748491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602255292 | ||||||||
| FaxNumber: | 3602256097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | HUGHES | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3604239535 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7072184 | 05 | WA | MEDICAID | DC3748 | 01 | WA | MEDICARE RAILROAD | OTHER |