Provider Demographics
NPI:1306947841
Name:SOUTH WHIDBEY PHYSICAL THERAPY AND SPORTS CLINIC INC
Entity type:Organization
Organization Name:SOUTH WHIDBEY PHYSICAL THERAPY AND SPORTS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GOETZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:360-341-1299
Mailing Address - Street 1:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WA
Mailing Address - Zip Code:98236-0643
Mailing Address - Country:US
Mailing Address - Phone:360-341-1299
Mailing Address - Fax:360-341-1277
Practice Address - Street 1:11042 SR 525 # 134
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:WA
Practice Address - Zip Code:98236-8618
Practice Address - Country:US
Practice Address - Phone:360-341-1299
Practice Address - Fax:360-341-1277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601918262261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0181085OtherDEPT OF LABOR AND INDUSTR
WA7092463Medicaid
WAGAB08089Medicare UPIN