Healthcare Provider Details

I. General information

NPI: 1235189135
Provider Name (Legal Business Name): PHASE 1 PHYSICAL THERAPY PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5928 HIGHWAY 291
NINE MILE FALLS WA
99026-9525
US

IV. Provider business mailing address

PO BOX 549
NINE MILE FALLS WA
99026-0549
US

V. Phone/Fax

Practice location:
  • Phone: 509-465-5663
  • Fax: 509-467-8663
Mailing address:
  • Phone: 509-465-5663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOEL T SAN NICOLAS
Title or Position: ADMINISTRATOR
Credential: PT
Phone: 509-465-5663