=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912902347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KITSAP PHYSICAL THERAPY AND SPORTS CLINIC PS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2005
-----------------------------------------------------
Last Update Date | 05/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 NW MYHRE RD STE 101
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-7672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-598-3764
-----------------------------------------------------
Fax | 360-598-3282
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2400 NW MYHRE RD STE 101
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-7672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-598-3764
-----------------------------------------------------
Fax | 360-598-3282
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HRD
-----------------------------------------------------
Name | SUMMER ZUMWALT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-598-3764
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------