Healthcare Provider Details

I. General information

NPI: 1164546016
Provider Name (Legal Business Name): WATERFRONT SPORTS AND PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2007
Last Update Date: 12/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20109 AURORA AVE N STE 105
SHORELINE WA
98133-3127
US

IV. Provider business mailing address

20109 AURORA AVE N STE 105
SHORELINE WA
98133-3127
US

V. Phone/Fax

Practice location:
  • Phone: 206-801-7546
  • Fax: 206-801-7547
Mailing address:
  • Phone: 206-801-7546
  • Fax: 206-801-7547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM C REYNOLDS
Title or Position: PRESIDENT
Credential:
Phone: 206-801-7546