Provider Demographics
NPI:1700054186
Name:EAGLE ROCK PHYSICAL THERAPY, PS
Entity Type:Organization
Organization Name:EAGLE ROCK PHYSICAL THERAPY, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISENHART
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:509-689-4301
Mailing Address - Street 1:PO BOX 769
Mailing Address - Street 2:411 HOSPITAL WAY
Mailing Address - City:BREWSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98812-0769
Mailing Address - Country:US
Mailing Address - Phone:509-689-4301
Mailing Address - Fax:509-689-4307
Practice Address - Street 1:411 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812
Practice Address - Country:US
Practice Address - Phone:509-689-4301
Practice Address - Fax:509-689-4307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7131659Medicaid
WA7131659Medicaid