Healthcare Provider Details

I. General information

NPI: 1265433601
Provider Name (Legal Business Name): MARK R DUTTON MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 NE ROMANCE HILL RD STE 101
BELFAIR WA
98528-0457
US

IV. Provider business mailing address

PO BOX 457 21 NE ROMANCE HILL RD STE 101
BELFAIR WA
98528-9626
US

V. Phone/Fax

Practice location:
  • Phone: 360-275-6612
  • Fax: 360-275-6658
Mailing address:
  • Phone: 360-275-6612
  • Fax: 360-275-6658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00007051
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: