Provider Demographics
NPI:1700920782
Name:PROFESSIONAL RECREATION ORGANIZATION, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL RECREATION ORGANIZATION, INC.
Other - Org Name:PRO SPORTS CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR OF ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-869-4746
Mailing Address - Street 1:4455 148TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3120
Mailing Address - Country:US
Mailing Address - Phone:425-895-6546
Mailing Address - Fax:425-861-6277
Practice Address - Street 1:4455 148TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3120
Practice Address - Country:US
Practice Address - Phone:425-895-6546
Practice Address - Fax:425-861-6277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600541508207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty