Provider Demographics
NPI:1407837453
Name:LAKE CHELAN PHYSICAL THERAPY, PS
Entity type:Organization
Organization Name:LAKE CHELAN PHYSICAL THERAPY, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-682-4713
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-0006
Mailing Address - Country:US
Mailing Address - Phone:509-682-4713
Mailing Address - Fax:509-682-3218
Practice Address - Street 1:123 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816
Practice Address - Country:US
Practice Address - Phone:509-682-4713
Practice Address - Fax:509-682-3218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA33460OtherCOMPANY L&I ID
WA7047947Medicaid
WA33460OtherCOMPANY L&I ID