Provider Demographics
NPI:1902930076
Name:HAZEL DELL SPORTS MEDICINE & REHAB CLINIC PLLC
Entity Type:Organization
Organization Name:HAZEL DELL SPORTS MEDICINE & REHAB CLINIC PLLC
Other - Org Name:FORGEY SPORTSMED & REHAB CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FORGEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-573-5500
Mailing Address - Street 1:300 GRAND BLVD
Mailing Address - Street 2:STE B200
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-4930
Mailing Address - Country:US
Mailing Address - Phone:360-573-5500
Mailing Address - Fax:360-573-9075
Practice Address - Street 1:300 GRAND BLVD
Practice Address - Street 2:STE B200
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4930
Practice Address - Country:US
Practice Address - Phone:360-573-5500
Practice Address - Fax:360-573-9075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA111N00000X
WAMD00010276207Q00000X, 207Q00000X
WACH00034484111N00000X
WAPT00006628225100000X
WAOT00002543225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0154878OtherDEPARTMENT OF LABOR & IND
WA0154878OtherDEPARTMENT OF LABOR & IND