Provider Demographics
NPI:1689854366
Name:PERSONAL PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PERSONAL PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARIUSZ
Authorized Official - Middle Name:
Authorized Official - Last Name:STAWOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-946-9007
Mailing Address - Street 1:702 JADWIN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4256
Mailing Address - Country:US
Mailing Address - Phone:509-946-9007
Mailing Address - Fax:509-946-9755
Practice Address - Street 1:702 JADWIN AVE STE A
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4256
Practice Address - Country:US
Practice Address - Phone:509-946-9007
Practice Address - Fax:509-946-9755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008664261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0195507OtherL&I
WA7136021Medicaid
WA0195507OtherL&I
WA7136021Medicaid