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General NPI Number Information
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NPI Number | 1801920566
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Entity Type | Organization
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Legal Business Name | GREENLAKE SPORTS PHYSICAL THERAPY
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Dates
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Enumeration Date | 03/15/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7209 WOODLAWN AVE NE
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City | SEATTLE
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State | WA
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Zip | 98115-5335
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Country | US
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Telephone | 206-524-5115
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Fax | 206-524-2456
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Provider Business Mailing Address
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Address Line | 7209 WOODLAWN AVE NE
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City | SEATTLE
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State | WA
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Zip | 98115-5335
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Country | US
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Telephone | 206-524-5115
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Fax | 206-524-2456
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Authorized Official
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Title or Position | OWNERPRESIDENT
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Name | MR. BART D SIMONS
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Credential | PT
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Telephone | 206-524-5115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT00004077
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License Number State | WA
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