MEDICARE: PACIFIC NORTHWEST PHYSICAL THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	23616	CA

General Provider Information

NPI Number	:	1134506454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC NORTHWEST PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	225 I ST
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531-4305
Country	:	US
Telephone Number	:	707-464-9511
Fax Number	:	707-464-9513

Provider Business Practice Location Address
First Line	:	225 I ST
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531-4305
Country	:	US
Telephone Number	:	707-464-9511
Fax Number	:	707-464-9513

Authorized Official
Title or Position	:	OWNER
Name	:	MR. BRADLEY KIME
Credential	:	PT,OCS,CMPT
Telephone Number	:	707-464-9511

Provider Enumeration Date	:	05/06/2015
Last Update Date	:	05/06/2015

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Directions to “PACIFIC NORTHWEST PHYSICAL THERAPY ” Practice Location

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