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General NPI Number Information
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NPI Number | 1134894652
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Entity Type | Organization
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Legal Business Name | NORTHWEST SPORTS PERFORMANCE
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Dates
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Enumeration Date | 08/16/2021
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Last Update Date | 08/16/2021
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Provider Practice Location Address
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Address Line | 15916 93RD AVE E
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City | PUYALLUP
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State | WA
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Zip | 98375-6718
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Country | US
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Telephone | 206-383-3186
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Fax |
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Provider Business Mailing Address
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Address Line | 15916 93RD AVE E
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City | PUYALLUP
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State | WA
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Zip | 98375-6718
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Country | US
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Telephone | 206-383-3186
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Fax |
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Authorized Official
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Title or Position | LMT
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Name | KEVIN VANDENBOSCH
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Credential | LMT
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Telephone | 206-383-3186
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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