Provider Demographics
NPI:1447384235
Name:PEAK FITNESS PHYSICAL THERAPY, PS
Entity Type:Organization
Organization Name:PEAK FITNESS PHYSICAL THERAPY, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:VAN PEVENAGE
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:509-725-7325
Mailing Address - Street 1:PO BOX 752
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99122-0752
Mailing Address - Country:US
Mailing Address - Phone:509-725-7325
Mailing Address - Fax:509-725-5325
Practice Address - Street 1:506 MORGAN STREET
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:WA
Practice Address - Zip Code:99122-0752
Practice Address - Country:US
Practice Address - Phone:509-725-7325
Practice Address - Fax:509-725-5325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7125768Medicaid
WAP00335661OtherPALMETTO
WA0205378OtherL & I
WAG8858340Medicare ID - Type Unspecified