Provider Demographics
NPI:1295919181
Name:NORTHLAKE REHABILITATION, LLC
Entity type:Organization
Organization Name:NORTHLAKE REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:URBAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-806-5721
Mailing Address - Street 1:18323 BOTHELL EVERETT HWY STE 220
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-5246
Mailing Address - Country:US
Mailing Address - Phone:425-806-5700
Mailing Address - Fax:425-806-5701
Practice Address - Street 1:18600 WOODINVILLE SNOHOMISH RD NE
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-8531
Practice Address - Country:US
Practice Address - Phone:425-488-6640
Practice Address - Fax:425-488-5424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7110141Medicaid
WAGAB28304Medicare PIN