Basic Information
| Provider Information | |||||||||
| NPI: | 1508208596 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PT NORTHWEST OF LONGVIEW, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAPITOL PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986323229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604239535 | ||||||||
| FaxNumber: | 3604149284 | ||||||||
| Practice Location | |||||||||
| Address1: | 4770 YELM HWY SE | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985034986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604916074 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 10/01/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUGHES | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3604239535 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.