MEDICARE: WESTSIDE PHYSICAL THERAPY AND SPORTS MEDICINE INC PS

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	225X00000X	Occupational Therapist	600-454-078	WA
2	225100000X	Physical Therapist	600-454-078	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0148298	OTHER	WA	DEPT OF L & I

General Provider Information

NPI Number	:	1821080987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTSIDE PHYSICAL THERAPY AND SPORTS MEDICINE INC PS

Provider Business Mailing Address
First Line	:	1213 S 40TH AVE
Second Line	:
City	:	YAKIMA
State	:	WA
Zip	:	98908-3961
Country	:	US
Telephone Number	:	509-966-8981
Fax Number	:	509-966-2125

Provider Business Practice Location Address
First Line	:	1213 S 40TH AVE
Second Line	:
City	:	YAKIMA
State	:	WA
Zip	:	98908-3961
Country	:	US
Telephone Number	:	509-966-8981
Fax Number	:	509-966-2125

Authorized Official
Title or Position	:	OWNER DIRECTOR
Name	:	MR. JOHN LAWRENCE BUTTS
Credential	:	PHYSICAL THERAPIST
Telephone Number	:	509-966-8981

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	12/30/2011

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