=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518246495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLYMPIC REHAB ASSOCIATES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2011
-----------------------------------------------------
Last Update Date | 07/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 LAWRENCE ST 101
-----------------------------------------------------
City | PORT TOWNSEND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98368-6559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-385-1035
-----------------------------------------------------
Fax | 360-385-4395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 FAWN LN
-----------------------------------------------------
City | SEQUIM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98382-3852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-681-2825
-----------------------------------------------------
Fax | 360-385-4395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, THERAPIST
-----------------------------------------------------
Name | RICHARD PAUL PEREZ
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 951-205-0885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT60132077
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------