Basic Information
Provider Information | |||||||||
NPI: | 1821107459 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOSS | ||||||||
FirstName: | KURT | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11009 | ||||||||
Address2: | CASCADE BILLING | ||||||||
City: | OLYMPIA | ||||||||
State: | WA | ||||||||
PostalCode: | 985081009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603522037 | ||||||||
FaxNumber: | 3603520637 | ||||||||
Practice Location | |||||||||
Address1: | 3333 HARRISON AVE | ||||||||
Address2: | SUITE 102 | ||||||||
City: | OLYMPIA | ||||||||
State: | WA | ||||||||
PostalCode: | 98502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3602927245 | ||||||||
FaxNumber: | 3602927247 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2006 | ||||||||
LastUpdateDate: | 01/18/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00004067 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 8443756 | 05 | WA |   | MEDICAID | 0204808 | 01 | WA | L & I | OTHER |