Provider Demographics
NPI:1558618322
Name:VILLAGE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:VILLAGE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:E
Authorized Official - Last Name:IRWIN-SIRES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPT, OCS
Authorized Official - Phone:206-498-8496
Mailing Address - Street 1:5124 NE LATIMER PL
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-4954
Mailing Address - Country:US
Mailing Address - Phone:206-498-8496
Mailing Address - Fax:
Practice Address - Street 1:5417 IVANHOE PL NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-2838
Practice Address - Country:US
Practice Address - Phone:206-498-8496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00006079261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy