Provider Demographics
NPI:1194934091
Name:PREMIER PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:PREMIER PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:PURCELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:360-636-4360
Mailing Address - Street 1:118 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3017
Mailing Address - Country:US
Mailing Address - Phone:360-636-4360
Mailing Address - Fax:360-425-5250
Practice Address - Street 1:1118 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3017
Practice Address - Country:US
Practice Address - Phone:360-636-4360
Practice Address - Fax:360-425-5250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0162-456OtherDEPARTMENT OF L&I
WA7072861Medicaid
WA0162-456OtherDEPARTMENT OF L&I