Healthcare Provider Details

I. General information

NPI: 1811945900
Provider Name (Legal Business Name): KITSAP PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 POTTERY AVE SUITE 100
PORT ORCHARD WA
98366-2518
US

IV. Provider business mailing address

1880 POTTERY AVE SUITE 100
PORT ORCHARD WA
98366-2518
US

V. Phone/Fax

Practice location:
  • Phone: 360-895-9090
  • Fax: 360-895-9089
Mailing address:
  • Phone: 360-895-9090
  • Fax: 360-895-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number602080097
License Number StateWA

VIII. Authorized Official

Name: MR. JOHN ROBERT CARLSON
Title or Position: OWNER
Credential: PT
Phone: 360-895-9090