MEDICARE: TRACY VIGUS PHYSICAL THERAPIST

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	PT00005714	WA

General Provider Information

NPI Number	:	1497816391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY VIGUS PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	4200 6TH AVE SE
Second Line	:
City	:	LACEY
State	:	WA
Zip	:	98503-1042
Country	:	US
Telephone Number	:	360-459-8311
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 6TH AVE SE
Second Line	:
City	:	LACEY
State	:	WA
Zip	:	98503-1042
Country	:	US
Telephone Number	:	360-459-8311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	12/11/2023

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