Provider Demographics
NPI:1073669412
Name:NORTH SPOKANE PHYSICAL & SPORTS THERAPY LLC
Entity Type:Organization
Organization Name:NORTH SPOKANE PHYSICAL & SPORTS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-483-8228
Mailing Address - Street 1:203 E DALKE AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-8112
Mailing Address - Country:US
Mailing Address - Phone:509-483-8228
Mailing Address - Fax:509-483-8338
Practice Address - Street 1:203 E DALKE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-8112
Practice Address - Country:US
Practice Address - Phone:509-483-8228
Practice Address - Fax:509-483-8338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005023225100000X
WAPT00008140225100000X
WAPT00009478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5430PEOtherASURIS
WADB3601OtherRR MEDICARE GROUP
WA216184OtherLABOR AND INDUSTRIES
WA7135395Medicaid
WA7135395Medicaid
WAG8800296Medicare PIN