Basic Information
| Provider Information | |||||||||
| NPI: | 1407282734 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EPIC PT HEALTH & PERFORMANCE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EPIC PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5006 CENTER ST STE N | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984092314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534763333 | ||||||||
| FaxNumber: | 2534763334 | ||||||||
| Practice Location | |||||||||
| Address1: | 5006 CENTER ST STE N | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984092314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534763333 | ||||||||
| FaxNumber: | 2534763334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2013 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | AHDUT | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2532231594 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 603331038 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.