Provider Demographics
NPI:1134315294
Name:LOUDON ORTHOSPORT PT, LLC
Entity Type:Organization
Organization Name:LOUDON ORTHOSPORT PT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:LOUDON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-764-7246
Mailing Address - Street 1:2200 S MAIERS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-8818
Mailing Address - Country:US
Mailing Address - Phone:509-764-7246
Mailing Address - Fax:
Practice Address - Street 1:2200 S MAIERS RD
Practice Address - Street 2:SUITE C
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-8818
Practice Address - Country:US
Practice Address - Phone:509-764-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007801225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8852174Medicare PIN