Provider Demographics
NPI:1144543323
Name:OUTPATIENT PHYSICAL THERAPY & SPORTS REHABILITATION,INC, PC
Entity type:Organization
Organization Name:OUTPATIENT PHYSICAL THERAPY & SPORTS REHABILITATION,INC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL AND FACILITY MANAGEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-413-4427
Mailing Address - Street 1:26837 MAPLE VALLEY HIGHWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-9917
Mailing Address - Country:US
Mailing Address - Phone:425-413-4427
Mailing Address - Fax:
Practice Address - Street 1:8009 S 180TH STE
Practice Address - Street 2:112
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-1042
Practice Address - Country:US
Practice Address - Phone:425-226-7827
Practice Address - Fax:425-251-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB11700OtherMEDICARE PTAN
WA7086606Medicaid
WA7086606Medicaid