Provider Demographics
NPI:1588774491
Name:SEQUIM PHYSICAL THERAPY CENTER, PS
Entity type:Organization
Organization Name:SEQUIM PHYSICAL THERAPY CENTER, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILWERT
Authorized Official - Suffix:
Authorized Official - Credentials:MPT OCS
Authorized Official - Phone:360-683-0632
Mailing Address - Street 1:500 W FIR ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3201
Mailing Address - Country:US
Mailing Address - Phone:360-683-0632
Mailing Address - Fax:360-681-5483
Practice Address - Street 1:500 W FIR ST
Practice Address - Street 2:SUITE A
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3201
Practice Address - Country:US
Practice Address - Phone:360-683-0632
Practice Address - Fax:360-681-5483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6022916710010001261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7117260Medicaid
0173768OtherWORKMANS COMP DEPT OF L&I
WAGAB37225Medicare UPIN
WAGAB37225Medicare ID - Type Unspecified