Basic Information
| Provider Information | |||||||||
| NPI: | 1851712202 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PELVIC REHAB SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2170 | ||||||||
| Address2: | |||||||||
| City: | SUMNER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983900480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538402313 | ||||||||
| FaxNumber: | 2538406340 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 LIMITED LN NW | ||||||||
| Address2: | SUITE B | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985022638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607090700 | ||||||||
| FaxNumber: | 3607090703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2014 | ||||||||
| LastUpdateDate: | 01/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2538406448 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.