MEDICARE: SOUTH WHIDBEY PHYSICAL THERAPY AND SPORTS CLINIC INC

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	601918262	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0181085	OTHER	WA	DEPT OF LABOR AND INDUSTR
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306947841
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH WHIDBEY PHYSICAL THERAPY AND SPORTS CLINIC INC

Provider Business Mailing Address
First Line	:	PO BOX 643
Second Line	:
City	:	CLINTON
State	:	WA
Zip	:	98236-0643
Country	:	US
Telephone Number	:	360-341-1299
Fax Number	:	360-341-1277

Provider Business Practice Location Address
First Line	:	11042 SR 525 # 134
Second Line	:
City	:	CLINTON
State	:	WA
Zip	:	98236-8618
Country	:	US
Telephone Number	:	360-341-1299
Fax Number	:	360-341-1277

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	ANDREW JOSEPH GOETZ
Credential	:	PT
Telephone Number	:	360-341-1299

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	10/17/2023

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