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General NPI Number Information
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NPI Number | 1740689520
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Entity Type | Organization
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Legal Business Name | G4 ATHLETE LLC
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Dates
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Enumeration Date | 08/18/2014
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Last Update Date | 08/18/2014
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Provider Practice Location Address
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Address Line | 2737 77TH AVE SE SUITE 214
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City | MERCER ISLAND
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State | WA
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Zip | 98040-2830
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Country | US
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Telephone | 206-518-9405
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Fax | 855-819-0086
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Provider Business Mailing Address
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Address Line | 2737 77TH AVE SE SUITE 214
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City | MERCER ISLAND
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State | WA
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Zip | 98040-2830
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Country | US
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Telephone | 206-518-9405
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST/CLINIC OWNER
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Name | MR. BRENT M GEORGE
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Credential | MPT
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Telephone | 206-518-9405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number | 603186027
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License Number State | WA
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