=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275766172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRETCH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2009
-----------------------------------------------------
Last Update Date | 08/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 YALE AVE N
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98109-5430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-624-7602
-----------------------------------------------------
Fax | 206-624-7606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 YALE AVE N
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98109-5430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-624-7602
-----------------------------------------------------
Fax | 206-624-7606
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/FOUNDER
-----------------------------------------------------
Name | MR. WOLFGANG E BROLLEY
-----------------------------------------------------
Credential | RPT,LMP,RC
-----------------------------------------------------
Telephone | 206-624-7602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 602622922
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------