Provider Demographics
NPI:1558310375
Name:OLYMPIC SPORTS AND SPINE REHABILITATION PS
Entity type:Organization
Organization Name:OLYMPIC SPORTS AND SPINE REHABILITATION PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:VERN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ESSENBERG
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:253-581-5200
Mailing Address - Street 1:9315 GRAVELLY LAKE DR SW
Mailing Address - Street 2:SUITE 306
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1574
Mailing Address - Country:US
Mailing Address - Phone:253-581-5200
Mailing Address - Fax:253-581-5203
Practice Address - Street 1:8011 112TH STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-7814
Practice Address - Country:US
Practice Address - Phone:253-848-0662
Practice Address - Fax:253-848-8567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA42640OtherLABOR & INDUSTRIES
WA8930571OtherL & I CRIME VICTIM PRGM
WA192149400OtherOWCP
WAPO9605OtherREGENCE BLUE SHIELD
WA7130271Medicaid
WA7681703Medicaid
WACT1246OtherRAILROAD MEDICARE
WACT1246OtherRAILROAD MEDICARE