Healthcare Provider Details

I. General information

NPI: 1558310375
Provider Name (Legal Business Name): OLYMPIC SPORTS AND SPINE REHABILITATION PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8011 112TH STREET CT E
PUYALLUP WA
98373-7814
US

IV. Provider business mailing address

9315 GRAVELLY LAKE DR SW SUITE 306
LAKEWOOD WA
98499-1574
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-0662
  • Fax: 253-848-8567
Mailing address:
  • Phone: 253-581-5200
  • Fax: 253-581-5203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. VERN J ESSENBERG JR.
Title or Position: CHIEF OPERATIONS OFFICER
Credential: PT
Phone: 253-581-5200