Provider Demographics
NPI:1154574614
Name:PHYSICAL THERAPY ASSOCIATES OF CAMAS
Entity type:Organization
Organization Name:PHYSICAL THERAPY ASSOCIATES OF CAMAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:GUY
Authorized Official - Last Name:SANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, CSCS
Authorized Official - Phone:360-834-7760
Mailing Address - Street 1:1918 SE 283RD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-9509
Mailing Address - Country:US
Mailing Address - Phone:360-834-7760
Mailing Address - Fax:360-834-2756
Practice Address - Street 1:414 NE 3RD AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2154
Practice Address - Country:US
Practice Address - Phone:360-834-7760
Practice Address - Fax:360-834-2756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00008543261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7111628Medicaid
WA261Q00000XOtherTAXONOMY
WAGAB27809Medicare PIN
WA261Q00000XOtherTAXONOMY