=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003982745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TWIN RIVERS PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2006
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 6TH ST STE 101
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99403-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-758-8510
-----------------------------------------------------
Fax | 509-751-9149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 6TH ST STE 101
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99403-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-758-8510
-----------------------------------------------------
Fax | 509-751-9149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PT OWNER
-----------------------------------------------------
Name | MR. BRENT W WAHLBERG JR.
-----------------------------------------------------
Credential | RPT
-----------------------------------------------------
Telephone | 509-758-8510
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT396
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT00005041
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------