Provider Demographics
NPI:1114770872
Name:PERFORMANCE MYOTHERAPY NW LLC
Entity Type:Organization
Organization Name:PERFORMANCE MYOTHERAPY NW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:425-343-8267
Mailing Address - Street 1:11132 17TH ST SE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-7939
Mailing Address - Country:US
Mailing Address - Phone:425-343-8267
Mailing Address - Fax:425-374-3435
Practice Address - Street 1:11545 15TH AVE NE STE 305
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-6358
Practice Address - Country:US
Practice Address - Phone:425-343-8267
Practice Address - Fax:425-374-3435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty