Provider Demographics
NPI:1265523609
Name:OLYMPIC PHYSICAL THERAPY
Entity type:Organization
Organization Name:OLYMPIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:HARBAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:415-383-6789
Mailing Address - Street 1:1 BLACKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-2053
Mailing Address - Country:US
Mailing Address - Phone:415-383-6789
Mailing Address - Fax:415-383-6744
Practice Address - Street 1:1 BLACKFIELD DR
Practice Address - Street 2:
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-2053
Practice Address - Country:US
Practice Address - Phone:415-383-6789
Practice Address - Fax:415-383-6744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DF6085OtherRAILROAD MEDICARE
CAZZZ03199ZMedicare PIN