Healthcare Provider Details

I. General information

NPI: 1700553674
Provider Name (Legal Business Name): PEAK SPORTS & SPINE PHYSICAL THERAPY - MAPLE VALLEY PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22443 SE 240TH ST STE 201
MAPLE VALLEY WA
98038-5879
US

IV. Provider business mailing address

22443 SE 240TH ST STE 201
MAPLE VALLEY WA
98038-5879
US

V. Phone/Fax

Practice location:
  • Phone: 425-306-4265
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: RUSSELL KOWALINSKI
Title or Position: OWNER
Credential: PT, DPT
Phone: 425-584-7704