Provider Demographics
NPI:1740408905
Name:PEAK SPORTS AND SPINE PT-ISSAQUAH P S
Entity Type:Organization
Organization Name:PEAK SPORTS AND SPINE PT-ISSAQUAH P S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SWWINSCOE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MPT
Authorized Official - Phone:425-391-9211
Mailing Address - Street 1:1445 NW MALL STREET
Mailing Address - Street 2:STE. 1
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027
Mailing Address - Country:US
Mailing Address - Phone:425-391-9211
Mailing Address - Fax:425-391-9545
Practice Address - Street 1:1445 NW MALL STREET
Practice Address - Street 2:STE. 1
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027
Practice Address - Country:US
Practice Address - Phone:425-391-9211
Practice Address - Fax:425-391-9545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005443225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8856846Medicare ID - Type UnspecifiedPHYSICAL THERAPIST
WAGAB16809Medicare ID - Type UnspecifiedPHYSICAL THERAPIST
WAG8800882Medicare ID - Type UnspecifiedPHYSICAL THERAPIST
WAGAB12103Medicare ID - Type UnspecifiedPHYSCIAL THERAPIST
GAB12102Medicare PIN