Basic Information
| Provider Information | |||||||||
| NPI: | 1396914628 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH SOUND HEALTH & FITNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 A LIMITED LN NW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609439570 | ||||||||
| FaxNumber: | 3607544517 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960 A LIMITED LN NW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609439570 | ||||||||
| FaxNumber: | 3607544517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2008 | ||||||||
| LastUpdateDate: | 02/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3607099500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.