Provider Demographics
NPI:1629250980
Name:OLYMPIC SPINE AND SPORTS THERAPY PC
Entity Type:Organization
Organization Name:OLYMPIC SPINE AND SPORTS THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-774-2411
Mailing Address - Street 1:6603 220TH ST SW
Mailing Address - Street 2:STE 102
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-2186
Mailing Address - Country:US
Mailing Address - Phone:425-774-2411
Mailing Address - Fax:425-672-7065
Practice Address - Street 1:6603 220TH ST SW
Practice Address - Street 2:STE 102
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2186
Practice Address - Country:US
Practice Address - Phone:425-774-2411
Practice Address - Fax:425-672-7065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001890111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB21076Medicare PIN