Basic Information
| Provider Information | |||||||||
| NPI: | 1699713370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVERETT PHYSICAL THERAPY AND SPORT PERFORMANCE CENTER PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEWITT AVE STE 115 | ||||||||
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| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982013600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252523908 | ||||||||
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| Address1: | 2000 HEWITT AVE | ||||||||
| Address2: | #115 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252523908 | ||||||||
| FaxNumber: | 4252527940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | BINSTEIN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7132977052 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
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 |
ID Information
| ID | Type | State | Issuer | Description | 4702EV | 01 | WA | REGENCE BLUESHIELD GRP # | OTHER | 8931865 | 01 | WA | L&I CRIME VICTIMS | OTHER | 9054974 | 05 | WA | MEDICAID | 2029657-00 | 01 | WA | OWCP | OTHER | 7121858 | 05 | WA | MEDICAID | 0179003 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER |