Provider Demographics
NPI:1235441197
Name:RADACK, BENJAMIN MICHAEL (DPT)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:RADACK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19319 7TH AVE NE
Mailing Address - Street 2:#108
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7442
Mailing Address - Country:US
Mailing Address - Phone:360-779-3777
Mailing Address - Fax:360-779-3797
Practice Address - Street 1:19319 7TH AVE NE
Practice Address - Street 2:#108
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7442
Practice Address - Country:US
Practice Address - Phone:360-779-3777
Practice Address - Fax:360-779-3797
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist