Provider Demographics
NPI:1649470501
Name:MEDICAL CENTER PHYSICAL THERAPY & SPORTS REHAB INC PS
Entity type:Organization
Organization Name:MEDICAL CENTER PHYSICAL THERAPY & SPORTS REHAB INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-453-3103
Mailing Address - Street 1:307 S 12TH AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3139
Mailing Address - Country:US
Mailing Address - Phone:509-453-3103
Mailing Address - Fax:509-453-2057
Practice Address - Street 1:307 S 12TH AVE STE 5
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3139
Practice Address - Country:US
Practice Address - Phone:509-453-3103
Practice Address - Fax:509-453-2057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00000697225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA13762OtherLABOR & INDUSTRIES
WA7037187Medicaid
WA13762OtherLABOR & INDUSTRIES