Provider Demographics
NPI:1326048364
Name:RENTON SPORTS & SPINE PT
Entity Type:Organization
Organization Name:RENTON SPORTS & SPINE PT
Other - Org Name:RENTON SPORTS & SPINE PT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST/CLINCI DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:425-917-9885
Mailing Address - Street 1:19400 108TH AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-0108
Mailing Address - Country:US
Mailing Address - Phone:425-917-9885
Mailing Address - Fax:253-277-0737
Practice Address - Street 1:19400 108TH AVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-0108
Practice Address - Country:US
Practice Address - Phone:425-917-9885
Practice Address - Fax:253-277-0737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7293608OtherCIGNA
WA8351397Medicaid
650021468OtherRR MEDICARE
WA147035OtherDEPT OF VTT
4465984OtherAETNA
WA5324J0OtherREGENCE BS