MEDICARE: PHASE 1 PHYSICAL THERAPY PS

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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235189135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHASE 1 PHYSICAL THERAPY PS

Provider Business Mailing Address
First Line	:	PO BOX 549
Second Line	:
City	:	NINE MILE FALLS
State	:	WA
Zip	:	99026-0549
Country	:	US
Telephone Number	:	509-465-5663
Fax Number	:

Provider Business Practice Location Address
First Line	:	5928 HIGHWAY 291
Second Line	:
City	:	NINE MILE FALLS
State	:	WA
Zip	:	99026-9525
Country	:	US
Telephone Number	:	509-465-5663
Fax Number	:	509-467-8663

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JOEL T SAN NICOLAS
Credential	:	PT
Telephone Number	:	509-465-5663

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	08/22/2020

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Directions to “PHASE 1 PHYSICAL THERAPY PS ” Practice Location

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