Provider Demographics
NPI:1356471684
Name:PINE LAKE PHYSICAL THERAPY & SPORTS REHAB, P.S.
Entity Type:Organization
Organization Name:PINE LAKE PHYSICAL THERAPY & SPORTS REHAB, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:ENYEART
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:425-391-4488
Mailing Address - Street 1:2850 228TH AVE SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-9301
Mailing Address - Country:US
Mailing Address - Phone:425-391-4488
Mailing Address - Fax:425-391-8287
Practice Address - Street 1:2850 228TH AVE SE
Practice Address - Street 2:SUITE B
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-9301
Practice Address - Country:US
Practice Address - Phone:425-391-4488
Practice Address - Fax:425-391-8287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000030472251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB18245Medicare ID - Type UnspecifiedMEDICARE GROUP