Provider Demographics
NPI:1104265412
Name:MARTHA LAKE PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:MARTHA LAKE PHYSICAL THERAPY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:425-672-2910
Mailing Address - Street 1:21009 76TH AVE W
Mailing Address - Street 2:C/O AXIS PHYSICAL THERAPY
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7126
Mailing Address - Country:US
Mailing Address - Phone:425-672-2910
Mailing Address - Fax:425-778-1872
Practice Address - Street 1:16406 7TH PL W
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-8100
Practice Address - Country:US
Practice Address - Phone:425-672-2910
Practice Address - Fax:425-778-1872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty