Provider Demographics
NPI:1124039870
Name:BELLEVUE SPORTS MEDICINE CLINIC INC
Entity Type:Organization
Organization Name:BELLEVUE SPORTS MEDICINE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEELY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOWALCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:425-455-0699
Mailing Address - Street 1:11400 SE 6TH ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6423
Mailing Address - Country:US
Mailing Address - Phone:425-455-0699
Mailing Address - Fax:425-455-1541
Practice Address - Street 1:11400 SE 6TH ST
Practice Address - Street 2:SUITE 130
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6423
Practice Address - Country:US
Practice Address - Phone:425-455-0699
Practice Address - Fax:425-455-1541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0030120OtherWA DEPT LABOR AND INDUSTR
WA0030120OtherWA DEPT LABOR AND INDUSTR