Provider Demographics
NPI:1982941001
Name:GROVER, BENJAMIN RANDOLPH (DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:RANDOLPH
Last Name:GROVER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 ORCHARD ST W
Mailing Address - Street 2:STE. 100
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6606
Mailing Address - Country:US
Mailing Address - Phone:253-564-1560
Mailing Address - Fax:253-564-4449
Practice Address - Street 1:4040 ORCHARD ST W
Practice Address - Street 2:STE. 100
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6606
Practice Address - Country:US
Practice Address - Phone:253-564-1560
Practice Address - Fax:253-564-4449
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60274732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0306754OtherSTATE OF WASHINGTON DEPT. OF LABOR AND INDUSTRIES
WA0306754OtherSTATE OF WASHINGTON DEPT. OF LABOR AND INDUSTRIES