Provider Demographics
NPI:1013107549
Name:KENT PHYSICAL THERAPY & SPORTS PERFORMANCE CENTER LLC
Entity Type:Organization
Organization Name:KENT PHYSICAL THERAPY & SPORTS PERFORMANCE CENTER LLC
Other - Org Name:ENGINEERED SPORTS THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:360-852-4587
Mailing Address - Street 1:2205 WALL ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3761
Mailing Address - Country:US
Mailing Address - Phone:425-512-8695
Mailing Address - Fax:425-512-8697
Practice Address - Street 1:2205 WALL ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3761
Practice Address - Country:US
Practice Address - Phone:425-512-8695
Practice Address - Fax:425-512-8697
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENT PHYSICAL THERAPY & SPORTS PERFORMANCE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-31
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008062261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0223987OtherDEPT OF LABOR & INDUSTRY