=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104568179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC PHYSICAL THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2022
-----------------------------------------------------
Last Update Date | 04/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3114 NW RANDALL WAY STE 300
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-7676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-625-9161
-----------------------------------------------------
Fax | 360-625-9215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 POTTERY AVE STE 110
-----------------------------------------------------
City | PORT ORCHARD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98366-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-329-7052
-----------------------------------------------------
Fax | 360-329-7053
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LAUREN M PALMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-329-7052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------