Provider Demographics
NPI:1871857946
Name:PROVAIL
Entity Type:Organization
Organization Name:PROVAIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HATZENBELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-826-1044
Mailing Address - Street 1:12550 AURORA AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8036
Mailing Address - Country:US
Mailing Address - Phone:206-363-7303
Mailing Address - Fax:
Practice Address - Street 1:12550 AURORA AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8036
Practice Address - Country:US
Practice Address - Phone:206-363-7303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60281347261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation