Provider Demographics
NPI:1245214543
Name:JERRY M JOHNSON ETAL PTR FOUR SEASONS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:JERRY M JOHNSON ETAL PTR FOUR SEASONS PHYSICAL THERAPY
Other - Org Name:FOUR SEASONS PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-327-1578
Mailing Address - Street 1:1111 W WELLESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-1274
Mailing Address - Country:US
Mailing Address - Phone:509-327-1578
Mailing Address - Fax:509-327-1596
Practice Address - Street 1:1111 W WELLESLEY AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-1274
Practice Address - Country:US
Practice Address - Phone:509-327-1578
Practice Address - Fax:509-327-1596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601871376261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7116312Medicaid
GAB15992Medicare ID - Type Unspecified