Provider Demographics
NPI:1205021276
Name:PEAK ORTHOPEDIC AND SPORTS PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:PEAK ORTHOPEDIC AND SPORTS PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS PT ATC
Authorized Official - Phone:360-794-7520
Mailing Address - Street 1:14841 179TH AVE SE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1127
Mailing Address - Country:US
Mailing Address - Phone:360-794-7520
Mailing Address - Fax:360-794-8947
Practice Address - Street 1:14841 179TH AVE SE
Practice Address - Street 2:SUITE 340
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1127
Practice Address - Country:US
Practice Address - Phone:360-794-7520
Practice Address - Fax:360-794-8947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT0000754261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7116288Medicaid