Provider Demographics
NPI:1306903182
Name:DEER PARK PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:DEER PARK PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-276-8811
Mailing Address - Street 1:707 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-0948
Mailing Address - Country:US
Mailing Address - Phone:509-276-8811
Mailing Address - Fax:866-629-4801
Practice Address - Street 1:707 S PARK ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006-0948
Practice Address - Country:US
Practice Address - Phone:509-276-8811
Practice Address - Fax:866-629-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7000474Medicaid
WAAB04397Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER