Healthcare Provider Details

I. General information

NPI: 1114214079
Provider Name (Legal Business Name): MADHU ENJATI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21200 E COUNTRY VISTA DR D101
LIBERTY LAKE WA
99019-7636
US

IV. Provider business mailing address

21200 E COUNTRY VISTA DR D101
LIBERTY LAKE WA
99019-7636
US

V. Phone/Fax

Practice location:
  • Phone: 623-521-8653
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60213179
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: