Provider Demographics
NPI:1528014875
Name:BIOSPORTS NORTHWEST PLLC
Entity Type:Organization
Organization Name:BIOSPORTS NORTHWEST PLLC
Other - Org Name:BIOSPORTS NORTHWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:DICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-947-8050
Mailing Address - Street 1:16007 NE 8TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008
Mailing Address - Country:US
Mailing Address - Phone:425-985-8915
Mailing Address - Fax:
Practice Address - Street 1:16007 NE 8TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008
Practice Address - Country:US
Practice Address - Phone:425-985-8915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
WAPT00002943261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8859607OtherMEDICARE #
WAG8859607OtherMEDICARE #