Provider Demographics
NPI:1427063890
Name:BUCKHOLZ, PRESTON OWEN (DPT)
Entity type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:OWEN
Last Name:BUCKHOLZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 881360
Mailing Address - Street 2:
Mailing Address - City:STEILACOOM
Mailing Address - State:WA
Mailing Address - Zip Code:98388-0410
Mailing Address - Country:US
Mailing Address - Phone:253-722-5511
Mailing Address - Fax:253-722-5496
Practice Address - Street 1:8509 STEILACOOM BLVD SW
Practice Address - Street 2:STE C
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498-4786
Practice Address - Country:US
Practice Address - Phone:253-722-5511
Practice Address - Fax:253-722-5496
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008534174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8330391Medicaid
WA7200132Medicaid
WA8330391Medicaid
WAG8857434Medicare ID - Type UnspecifiedPRESTON