Provider Demographics
NPI:1235353368
Name:CHEWELAH ORTHOPEDIC & SPORTS PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:CHEWELAH ORTHOPEDIC & SPORTS PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MOMT
Authorized Official - Phone:509-935-4988
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109-0909
Mailing Address - Country:US
Mailing Address - Phone:509-935-4988
Mailing Address - Fax:
Practice Address - Street 1:N 119 3RD ST E
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109
Practice Address - Country:US
Practice Address - Phone:509-935-4988
Practice Address - Fax:509-935-4985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0123911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7091564Medicaid
WA8446924Medicaid
WA8446924Medicaid
WA8856267Medicare ID - Type UnspecifiedMICHAEL V NOWACK
WAGAB25974Medicare ID - Type UnspecifiedROBERT R BREWER