Provider Demographics
NPI:1235189135
Name:PHASE 1 PHYSICAL THERAPY PS
Entity Type:Organization
Organization Name:PHASE 1 PHYSICAL THERAPY PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:SAN NICOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-465-5663
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:NINE MILE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99026-0549
Mailing Address - Country:US
Mailing Address - Phone:509-465-5663
Mailing Address - Fax:
Practice Address - Street 1:5928 HIGHWAY 291
Practice Address - Street 2:
Practice Address - City:NINE MILE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99026-9525
Practice Address - Country:US
Practice Address - Phone:509-465-5663
Practice Address - Fax:509-467-8663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7116437Medicaid