Provider Demographics
NPI:1881834448
Name:SPORTSMED PHYSICAL THERAPY, INC., P.S.
Entity Type:Organization
Organization Name:SPORTSMED PHYSICAL THERAPY, INC., P.S.
Other - Org Name:SPORTSMED PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:KERSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPT, OCS
Authorized Official - Phone:801-455-7329
Mailing Address - Street 1:PO BOX 11009
Mailing Address - Street 2:CASCADE BILLING
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-1009
Mailing Address - Country:US
Mailing Address - Phone:360-352-2037
Mailing Address - Fax:360-352-0637
Practice Address - Street 1:463 TREMONT STREET W.
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-0000
Practice Address - Country:US
Practice Address - Phone:360-895-1160
Practice Address - Fax:360-895-1161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty