Provider Demographics
NPI:1073725107
Name:BLACK DIAMOND SPORTS THERAPY, LLC
Entity Type:Organization
Organization Name:BLACK DIAMOND SPORTS THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAWNA
Authorized Official - Middle Name:N
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-663-7733
Mailing Address - Street 1:147 EASY WAY SUITE #106
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801
Mailing Address - Country:US
Mailing Address - Phone:509-663-7733
Mailing Address - Fax:509-663-3255
Practice Address - Street 1:147 EASY WAY SUITE #106
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801
Practice Address - Country:US
Practice Address - Phone:509-663-7733
Practice Address - Fax:509-663-3255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8855076Medicare ID - Type Unspecified