Healthcare Provider Details

I. General information

NPI: 1932224003
Provider Name (Legal Business Name): PT4GOLFLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12449 83RD PL NE
KIRKLAND WA
98034-2570
US

IV. Provider business mailing address

12449 83RD PL NE
KIRKLAND WA
98034-2570
US

V. Phone/Fax

Practice location:
  • Phone: 425-820-2810
  • Fax: 425-487-2804
Mailing address:
  • Phone: 425-820-2810
  • Fax: 425-487-2804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7490
License Number StateWA

VIII. Authorized Official

Name: GLENN MARK LIBMAN
Title or Position: OWNER
Credential: PT
Phone: 425-820-2810