Provider Demographics
NPI:1497476691
Name:GAME CHANGER PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:GAME CHANGER PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KACIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:SHIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:509-947-8600
Mailing Address - Street 1:705 S TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-4085
Mailing Address - Country:US
Mailing Address - Phone:509-934-3309
Mailing Address - Fax:509-852-7566
Practice Address - Street 1:5020 W CLEARWATER AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1951
Practice Address - Country:US
Practice Address - Phone:509-934-3309
Practice Address - Fax:509-852-7566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy