Provider Demographics
NPI:1811945900
Name:KITSAP PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:KITSAP PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:360-895-9090
Mailing Address - Street 1:1880 POTTERY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-2518
Mailing Address - Country:US
Mailing Address - Phone:360-895-9090
Mailing Address - Fax:360-895-9089
Practice Address - Street 1:1880 POTTERY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2518
Practice Address - Country:US
Practice Address - Phone:360-895-9090
Practice Address - Fax:360-895-9089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602080097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0150495OtherWA STATE DEPT OF LABOR IN
DB8089OtherRR MEDICARE
WA7105166Medicaid
WA7105166Medicaid