Provider Demographics
NPI:1407149164
Name:OLYMPIC REHAB CENTER
Entity Type:Organization
Organization Name:OLYMPIC REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MAREK
Authorized Official - Middle Name:W
Authorized Official - Last Name:PIATKOWSKI-NAZARRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-204-8797
Mailing Address - Street 1:1314 W GLENOAKS BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-3146
Mailing Address - Country:US
Mailing Address - Phone:818-204-8797
Mailing Address - Fax:
Practice Address - Street 1:1314 W GLENOAKS BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-3146
Practice Address - Country:US
Practice Address - Phone:818-204-8797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15084261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT15084OtherPT