Provider Demographics
NPI:1194857250
Name:LAKELAND SPORTS & SPINE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:LAKELAND SPORTS & SPINE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-939-7179
Mailing Address - Street 1:1408 LAKE TAPPS PKWY E
Mailing Address - Street 2:SUITE E106
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-8158
Mailing Address - Country:US
Mailing Address - Phone:253-939-7179
Mailing Address - Fax:253-939-7182
Practice Address - Street 1:1408 LAKE TAPPS PKWY E
Practice Address - Street 2:SUITE E106
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-8158
Practice Address - Country:US
Practice Address - Phone:253-939-7179
Practice Address - Fax:253-939-7182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2022-07-21
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
WA1B 5711LAOtherREGENCE
610775100OtherUSDOL
WAG2 176891OtherL&I
WAG8802582Medicare PIN