Provider Demographics
NPI:1821080987
Name:WESTSIDE PHYSICAL THERAPY AND SPORTS MEDICINE INC PS
Entity Type:Organization
Organization Name:WESTSIDE PHYSICAL THERAPY AND SPORTS MEDICINE INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:BUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:509-966-8981
Mailing Address - Street 1:1213 S 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3961
Mailing Address - Country:US
Mailing Address - Phone:509-966-8981
Mailing Address - Fax:509-966-2125
Practice Address - Street 1:1213 S 40TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3961
Practice Address - Country:US
Practice Address - Phone:509-966-8981
Practice Address - Fax:509-966-2125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600-454-078225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7682842Medicaid
WA0148298OtherDEPT OF L & I
WACK6405Medicare PIN
WAGAB08618Medicare PIN