MEDICARE: RENTON SPORTS & SPINE PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT00002862	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	650021468	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7293608	OTHER		CIGNA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	147035	OTHER	WA	DEPT OF VTT
5	4465984	OTHER		AETNA
6	5324J0	OTHER	WA	REGENCE BS

General Provider Information

NPI Number	:	1326048364
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENTON SPORTS & SPINE PT

Provider Business Mailing Address
First Line	:	19400 108TH AVE SE
Second Line	:	SUITE 100
City	:	KENT
State	:	WA
Zip	:	98031-0108
Country	:	US
Telephone Number	:	425-917-9885
Fax Number	:	253-277-0737

Provider Business Practice Location Address
First Line	:	19400 108TH AVE SE
Second Line	:	SUITE 100
City	:	KENT
State	:	WA
Zip	:	98031-0108
Country	:	US
Telephone Number	:	425-917-9885
Fax Number	:	253-277-0737

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/CLINCI DIRECTOR
Name	:	MR. JOEL M JOHNSON
Credential	:	PT
Telephone Number	:	425-917-9885

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	07/13/2016

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Directions to “RENTON SPORTS & SPINE PT ” Practice Location

Language	Start Address	Practice Location

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