Provider Demographics
NPI:1558503664
Name:PERFORMANCE SPORTS AND SPINE PHYSICAL THERAPY PS
Entity Type:Organization
Organization Name:PERFORMANCE SPORTS AND SPINE PHYSICAL THERAPY PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:ISMAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-353-1988
Mailing Address - Street 1:2726 GRIFFIN AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2362
Mailing Address - Country:US
Mailing Address - Phone:360-802-6757
Mailing Address - Fax:360-802-6756
Practice Address - Street 1:2726 GRIFFIN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2362
Practice Address - Country:US
Practice Address - Phone:360-802-6757
Practice Address - Fax:360-802-6756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty