Provider Demographics
NPI:1225113913
Name:CASCADE SPORT & SPINE REHABILITATION INC PC
Entity Type:Organization
Organization Name:CASCADE SPORT & SPINE REHABILITATION INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GALLANGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-748-1580
Mailing Address - Street 1:PO BOX 1338
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531
Mailing Address - Country:US
Mailing Address - Phone:360-748-1580
Mailing Address - Fax:360-748-1596
Practice Address - Street 1:145 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3037
Practice Address - Country:US
Practice Address - Phone:360-748-1580
Practice Address - Fax:360-748-1596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007726225100000X
WAPT00008819225100000X
WAPT00002809225100000X
WAPT00009536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7125966Medicaid
WAG8850914Medicare PIN