Provider Demographics
NPI:1790968766
Name:MAPLE VALLEY PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:MAPLE VALLEY PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:425-432-1671
Mailing Address - Street 1:22443 SE 240 ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038
Mailing Address - Country:US
Mailing Address - Phone:425-432-1671
Mailing Address - Fax:425-432-1677
Practice Address - Street 1:23870 SE KENT KANGLEY RD
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-6848
Practice Address - Country:US
Practice Address - Phone:425-432-1671
Practice Address - Fax:425-432-1677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5147174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA609471200OtherOWCP
WA5147OtherUPIN
WAP00279139OtherRAILROAD MEDICARE
WA0191071OtherL&I
WA0165RIOtherREGENCE
WA0191071OtherL&I
WA609471200OtherOWCP