Basic Information
| Provider Information | |||||||||
| NPI: | 1487795316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETTENCOURT | ||||||||
| FirstName: | RON | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PT, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12121 HARBOUR REACH DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982755314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254938313 | ||||||||
| FaxNumber: | 4254939614 | ||||||||
| Practice Location | |||||||||
| Address1: | 12121 HARBOUR REACH DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982755314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254938313 | ||||||||
| FaxNumber: | 4254939614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 03/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00003447 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8351116 | 05 | WA | MEDICAID |