Provider Demographics
NPI:1740382050
Name:MOUNTAIN PHYSICAL THERAPY AND SPORTS REHABILITATION LLC
Entity Type:Organization
Organization Name:MOUNTAIN PHYSICAL THERAPY AND SPORTS REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:PERRAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:360-832-8890
Mailing Address - Street 1:PO BOX 1837
Mailing Address - Street 2:
Mailing Address - City:EATONVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98328-1837
Mailing Address - Country:US
Mailing Address - Phone:360-832-8890
Mailing Address - Fax:360-832-8893
Practice Address - Street 1:313 CENTER STREET EAST
Practice Address - Street 2:SUITE 5
Practice Address - City:EATONVILLE
Practice Address - State:WA
Practice Address - Zip Code:98328
Practice Address - Country:US
Practice Address - Phone:360-832-8890
Practice Address - Fax:360-832-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003700261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7120846Medicaid
WA8850945Medicare ID - Type Unspecified