Provider Demographics
NPI:1720012065
Name:PROFORMANCE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PROFORMANCE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:BASHAW
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-338-9204
Mailing Address - Street 1:840 SE BISHOP BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5502
Mailing Address - Country:US
Mailing Address - Phone:509-338-9204
Mailing Address - Fax:
Practice Address - Street 1:840 SE BISHOP BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5502
Practice Address - Country:US
Practice Address - Phone:509-338-9204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
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
WA7127467Medicaid
WA0195909OtherDEPT. OF LABOR & INDUSTRY
WA0195909OtherDEPT. OF LABOR & INDUSTRY