Basic Information
| Provider Information | |||||||||
| NPI: | 1558492934 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT REHABILITATION PLLC | ||||||||
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| OtherOrganizationName: | SUMMIT REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2035 CORTE DEL NOGAL STE 200 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034866025 | ||||||||
| FaxNumber: | 8553597156 | ||||||||
| Practice Location | |||||||||
| Address1: | 9514 4TH ST NE UNIT 101 | ||||||||
| Address2: | |||||||||
| City: | LAKE STEVENS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982581937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253972327 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 02/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | PACE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2138041712 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7120637 | 05 | WA | MEDICAID | 7101587 | 05 | WA | MEDICAID | 7101611 | 05 | WA | MEDICAID | 710585 | 05 | WA | MEDICAID | 7101595 | 05 | WA | MEDICAID |