MEDICARE: BENJAMIN RANDOLPH GROVER DPT

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	PT60274732	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0306754	OTHER	WA	STATE OF WASHINGTON DEPT. OF LABOR AND INDUSTRIES

General Provider Information

NPI Number	:	1982941001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN RANDOLPH GROVER DPT

Provider Business Mailing Address
First Line	:	4040 ORCHARD ST W
Second Line	:	STE. 100
City	:	FIRCREST
State	:	WA
Zip	:	98466-6606
Country	:	US
Telephone Number	:	253-564-1560
Fax Number	:	253-564-4449

Provider Business Practice Location Address
First Line	:	4040 ORCHARD ST W
Second Line	:	STE. 100
City	:	FIRCREST
State	:	WA
Zip	:	98466-6606
Country	:	US
Telephone Number	:	253-564-1560
Fax Number	:	253-564-4449

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

Provider Enumeration Date	:	01/09/2013
Last Update Date	:	05/07/2013

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