Healthcare Provider Details

I. General information

NPI: 1588774491
Provider Name (Legal Business Name): SEQUIM PHYSICAL THERAPY CENTER, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FIR ST SUITE A
SEQUIM WA
98382-3201
US

IV. Provider business mailing address

500 W FIR ST SUITE A
SEQUIM WA
98382-3201
US

V. Phone/Fax

Practice location:
  • Phone: 360-683-0632
  • Fax: 360-681-5483
Mailing address:
  • Phone: 360-683-0632
  • Fax: 360-681-5483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number6022916710010001
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier7117260
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
Identifier0173768
Identifier TypeOTHER
Identifier State
Identifier IssuerWORKMANS COMP DEPT OF L&I

VIII. Authorized Official

Name: MR. JASON S WILWERT
Title or Position: BUSINESS OWNER
Credential: MPT OCS
Phone: 360-683-0632