Healthcare Provider Details

I. General information

NPI: 1174515894
Provider Name (Legal Business Name): OLYMPIC SPORTS & MANUAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 E FRONT ST STE C
PT ANGELES WA
98362-4636
US

IV. Provider business mailing address

1607 E FRONT ST STE C
PT ANGELES WA
98362-4636
US

V. Phone/Fax

Practice location:
  • Phone: 360-452-7798
  • Fax: 360-452-2772
Mailing address:
  • Phone: 360-452-7798
  • Fax: 360-452-2772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LORI J WEEKS
Title or Position: OFFICE MANAGER
Credential: PT
Phone: 360-452-7798