Basic Information
| Provider Information | |||||||||
| NPI: | 1982766440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SNOQUALMIE NORTH BEND PHYSICAL THERAPY PLLC | ||||||||
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| OtherOrganizationName: | NORTH BEND PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 118TH AVE SE STE 110 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980053875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254509474 | ||||||||
| FaxNumber: | 4254520704 | ||||||||
| Practice Location | |||||||||
| Address1: | 7713 CENTER BLVD SE STE 160 | ||||||||
| Address2: | |||||||||
| City: | SNOQUALMIE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980656309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254349607 | ||||||||
| FaxNumber: | 4254349582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | DIAZ | ||||||||
| AuthorizedOfficialFirstName: | DWAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4254509474 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7102924 | 05 | WA | MEDICAID |