Basic Information
| Provider Information | |||||||||
| NPI: | 1144305350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHADDURI | ||||||||
| FirstName: | LUCIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | BSPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ROMERO | ||||||||
| OtherFirstName: | LUCIE | ||||||||
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| OtherCredential: | BSPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 LIMITED LN NW | ||||||||
| Address2: | STE B | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985022638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607090700 | ||||||||
| FaxNumber: | 3607090703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00008806 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0291092 | 01 | WA | DEPT. OF LABOR AND INDUSTRIES | OTHER | 650023899 | 01 | WA | RAILROAD MEDICARE | OTHER | 8542KH | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8336786 | 05 | WA | MEDICAID | 8936913 | 01 | WA | CRIME VICTIMS | OTHER | 160515 | 01 | WA | DEPT OF LABOR & INDUSTRY | OTHER | A008 | 01 | WA | TRICARE | OTHER |