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General NPI Number Information
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NPI Number | 1104266451
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Entity Type | Organization
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Legal Business Name | PHYSICAL THERAPY NORTHWEST, PLLC
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Dates
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Enumeration Date | 07/01/2013
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Last Update Date | 07/01/2013
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Provider Practice Location Address
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Address Line | 319 WASHINGTON AVE S
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City | KENT
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State | WA
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Zip | 98032-5767
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Country | US
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Telephone | 206-909-9275
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Fax |
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Provider Business Mailing Address
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Address Line | 319 WASHINGTON AVE S
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City | KENT
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State | WA
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Zip | 98032-5767
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Country | US
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Telephone | 206-909-9275
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Fax |
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Authorized Official
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Title or Position | MANAGER/MEMBER
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Name | LUCAS ALLAN PREBLE
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Credential | P.T.
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Telephone | 206-909-9275
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT60177354
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License Number State | WA
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