MEDICARE: DR. JEFFREY KEITH KAWAGUCHI PT, PHD, ATC

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	2251X0800X	Orthopedic Physical Therapist	PT00003908	WA
2	2255A2300X	Athletic Trainer	A1 0047296	WA

General Provider Information

NPI Number	:	1912218603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY KEITH KAWAGUCHI PT, PHD, ATC

Provider Business Mailing Address
First Line	:	200 PHYSICAL EDUCATION BUILDING
Second Line	:
City	:	CHENEY
State	:	WA
Zip	:	99004-2476
Country	:	US
Telephone Number	:	509-359-7967
Fax Number	:	509-359-4833

Provider Business Practice Location Address
First Line	:	200 PHYSICAL EDUCATION BUILDING
Second Line	:
City	:	CHENEY
State	:	WA
Zip	:	99004-2476
Country	:	US
Telephone Number	:	509-359-7967
Fax Number	:	509-359-4833

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

Provider Enumeration Date	:	06/28/2010
Last Update Date	:	06/28/2010

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