Provider Demographics
NPI:1659427003
Name:CENTENNIAL SPORTS & PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:CENTENNIAL SPORTS & PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-928-6220
Mailing Address - Street 1:13102 E MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1142
Mailing Address - Country:US
Mailing Address - Phone:509-928-6220
Mailing Address - Fax:509-928-7597
Practice Address - Street 1:13102 E MISSION AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1142
Practice Address - Country:US
Practice Address - Phone:509-928-6220
Practice Address - Fax:509-928-7597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009613225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA196030OtherLABOR AND INDUSTRIES
WA7136989Medicaid
WADF5882OtherRR MEDICARE GROUP
WA5230FROtherASURIS
WAP00377246OtherRR MEDICARE
WA196030OtherLABOR AND INDUSTRIES
WA7136989Medicaid