Basic Information
| Provider Information | |||||||||
| NPI: | 1871827444 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MVP PHYSICAL THERAPY, INC. | ||||||||
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| OtherOrganizationName: | MVP PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| 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: | 14800 STARFIRE WAY | ||||||||
| Address2: | |||||||||
| City: | TUKWILA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062677811 | ||||||||
| FaxNumber: | 2062677813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2009 | ||||||||
| LastUpdateDate: | 11/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | GARLOCK | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 2535641560 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DSC, MHS, PT | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 7082225 | 05 | WA | MEDICAID |