Provider Demographics
NPI:1215142930
Name:SHELTON PHYSICAL THERAPY AND SPORTS MEDICINE CLINIC P.S.
Entity type:Organization
Organization Name:SHELTON PHYSICAL THERAPY AND SPORTS MEDICINE CLINIC P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER OF 100 PERCENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:ZYGAR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:360-426-5903
Mailing Address - Street 1:2300 KATI CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-1900
Mailing Address - Country:US
Mailing Address - Phone:360-426-5903
Mailing Address - Fax:360-426-5920
Practice Address - Street 1:2300 KATI CT
Practice Address - Street 2:SUITE B
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-1900
Practice Address - Country:US
Practice Address - Phone:360-426-5903
Practice Address - Fax:360-426-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002305261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7291404Medicaid
WA7291404Medicaid
WAR11873Medicare UPIN