Provider Demographics
NPI:1073614525
Name:VAN WAGNER VENTURES LLC
Entity Type:Organization
Organization Name:VAN WAGNER VENTURES LLC
Other - Org Name:INHOME REHAB OF WASHINGTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:VANWAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-595-5085
Mailing Address - Street 1:22710 126TH PL SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-3666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22710 126TH PL SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-3666
Practice Address - Country:US
Practice Address - Phone:206-595-5085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5028225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8862372Medicare PIN