Provider Demographics
NPI:1720050958
Name:LILAC CITY PHYSICAL THERAPY & SPORTS REHAB LLC
Entity Type:Organization
Organization Name:LILAC CITY PHYSICAL THERAPY & SPORTS REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROZIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-323-1494
Mailing Address - Street 1:28 E INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-2314
Mailing Address - Country:US
Mailing Address - Phone:509-323-1494
Mailing Address - Fax:509-323-1503
Practice Address - Street 1:28 E INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-2314
Practice Address - Country:US
Practice Address - Phone:509-323-1494
Practice Address - Fax:509-323-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7097207Medicaid
WA7097207Medicaid