Provider Demographics
NPI:1790955201
Name:QUAIL RUN PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:QUAIL RUN PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-648-3341
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:WA
Mailing Address - Zip Code:99171-0066
Mailing Address - Country:US
Mailing Address - Phone:509-648-3341
Mailing Address - Fax:509-648-4237
Practice Address - Street 1:13854 STATE ROUTE 23
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:WA
Practice Address - Zip Code:99171-9756
Practice Address - Country:US
Practice Address - Phone:509-648-3341
Practice Address - Fax:509-648-4237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3038261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT590902Medicare UPIN