Basic Information
Provider Information | |||||||||
NPI: | 1790743003 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MVP PHYSICAL THERAPY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MVP PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4040 ORCHARD ST. W. | ||||||||
Address2: | SUITE 100 | ||||||||
City: | FIRCREST | ||||||||
State: | WA | ||||||||
PostalCode: | 98466 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535641560 | ||||||||
FaxNumber: | 2535644449 | ||||||||
Practice Location | |||||||||
Address1: | 14207 MERIDIAN E STE A | ||||||||
Address2: |   | ||||||||
City: | PUYALLUP | ||||||||
State: | WA | ||||||||
PostalCode: | 98373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2537701807 | ||||||||
FaxNumber: | 9519737216 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 08/07/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOORE | ||||||||
AuthorizedOfficialFirstName: | MARGARITA | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING AND PROVIDER SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9516969353 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X |   | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   | 225100000X |   | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.