Healthcare Provider Details

I. General information

NPI: 1194993022
Provider Name (Legal Business Name): GREGORY NOELCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 SE VILLAGE LOOP
VANCOUVER WA
98683-8103
US

IV. Provider business mailing address

2911 SE VILLAGE LOOP
VANCOUVER WA
98683-8103
US

V. Phone/Fax

Practice location:
  • Phone: 360-433-6346
  • Fax: 360-891-4532
Mailing address:
  • Phone: 360-433-6346
  • Fax: 360-891-4532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00010733
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: