Provider Demographics
NPI:1609802230
Name:POINT FOSDICK PHYSICAL THERAPY, INC PS
Entity Type:Organization
Organization Name:POINT FOSDICK PHYSICAL THERAPY, INC PS
Other - Org Name:HARBOR PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLAKNEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:253-851-5718
Mailing Address - Street 1:4700 POINT FOSDICK DRIVE NW
Mailing Address - Street 2:SUITE 213
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335
Mailing Address - Country:US
Mailing Address - Phone:253-851-5718
Mailing Address - Fax:253-853-6922
Practice Address - Street 1:4700 POINT FOSDICK DRIVE NW
Practice Address - Street 2:SUITE 213
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335
Practice Address - Country:US
Practice Address - Phone:253-851-5718
Practice Address - Fax:253-853-6922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002125225100000X
WA601283625261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7095854Medicaid
WAGAB08916Medicare PIN
WA(G)AB08916Medicare UPIN