Provider Demographics
NPI:1144685306
Name:OLYMPIC SPORTS AND SPINE REHABILITATION, P.S.
Entity type:Organization
Organization Name:OLYMPIC SPORTS AND SPINE REHABILITATION, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:253-581-5200
Mailing Address - Street 1:9315 GRAVELLY LAKE DR SW
Mailing Address - Street 2:SUITE 306
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1574
Mailing Address - Country:US
Mailing Address - Phone:253-581-5200
Mailing Address - Fax:253-581-5203
Practice Address - Street 1:17520 MERIDIAN E
Practice Address - Street 2:SUITE F
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-6265
Practice Address - Country:US
Practice Address - Phone:253-864-7595
Practice Address - Fax:253-864-0457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-15
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty