Healthcare Provider Details

I. General information

NPI: 1457356404
Provider Name (Legal Business Name): WILLIAM R MACKENZIE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 03/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11802 NE 65TH ST 100
VANCOUVER WA
98662-5521
US

IV. Provider business mailing address

11802 NE 65TH ST 100
VANCOUVER WA
98662-5521
US

V. Phone/Fax

Practice location:
  • Phone: 360-253-6883
  • Fax: 360-892-7040
Mailing address:
  • Phone: 360-253-6883
  • Fax: 360-892-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00006628
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00034484
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: