Basic Information
| Provider Information | |||||||||
| NPI: | 1558310375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLYMPIC SPORTS AND SPINE REHABILITATION PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9315 GRAVELLY LAKE DR SW | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984991574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535815200 | ||||||||
| FaxNumber: | 2535815203 | ||||||||
| Practice Location | |||||||||
| Address1: | 8011 112TH STREET CT E | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983737814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538480662 | ||||||||
| FaxNumber: | 2538488567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | ESSENBERG | ||||||||
| AuthorizedOfficialFirstName: | VERN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2535815200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225700000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 42640 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8930571 | 01 | WA | L & I CRIME VICTIM PRGM | OTHER | 192149400 | 01 | WA | OWCP | OTHER | PO9605 | 01 | WA | REGENCE BLUE SHIELD | OTHER | 7130271 | 05 | WA | MEDICAID | 7681703 | 05 | WA | MEDICAID | CT1246 | 01 | WA | RAILROAD MEDICARE | OTHER |