Provider Demographics
NPI:1841255502
Name:JAVAMAN PS
Entity type:Organization
Organization Name:JAVAMAN PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SHORT-MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:360-733-4008
Mailing Address - Street 1:2075 BARKLEY BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-6696
Mailing Address - Country:US
Mailing Address - Phone:360-733-4008
Mailing Address - Fax:360-733-4064
Practice Address - Street 1:2075 BARKLEY BLVD
Practice Address - Street 2:STE 200
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-6696
Practice Address - Country:US
Practice Address - Phone:360-733-4008
Practice Address - Fax:360-733-4064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
WA601822178261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7087836Medicaid
WA0118842OtherLABOR AND INDUSTRY
WA393611001OtherGROUP HEALTH
193169300OtherUS DEPT OF LABOR
WA7087836Medicaid
WA0118842OtherLABOR AND INDUSTRY