Provider Demographics
NPI:1104040856
Name:PEDERSEN OUTPATIENT PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PEDERSEN OUTPATIENT PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:360-825-7411
Mailing Address - Street 1:1110 STEVENSON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2647
Mailing Address - Country:US
Mailing Address - Phone:360-825-7411
Mailing Address - Fax:360-825-7434
Practice Address - Street 1:1110 STEVENSON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2647
Practice Address - Country:US
Practice Address - Phone:360-825-7411
Practice Address - Fax:360-825-7434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB20955Medicare PIN