Provider Demographics
NPI:1134506454
Name:PACIFIC NORTHWEST PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIME
Authorized Official - Suffix:
Authorized Official - Credentials:PT,OCS,CMPT
Authorized Official - Phone:707-464-9511
Mailing Address - Street 1:225 I ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-4305
Mailing Address - Country:US
Mailing Address - Phone:707-464-9511
Mailing Address - Fax:707-464-9513
Practice Address - Street 1:225 I ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-4305
Practice Address - Country:US
Practice Address - Phone:707-464-9511
Practice Address - Fax:707-464-9513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23616261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGO803AMedicare UPIN