Provider Demographics
NPI:1053356717
Name:PACIFIC REHABILITATION & SPORTS MEDICINE INC
Entity type:Organization
Organization Name:PACIFIC REHABILITATION & SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:TARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-975-4503
Mailing Address - Street 1:4716 OLD GETTYSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055
Mailing Address - Country:US
Mailing Address - Phone:717-975-4503
Mailing Address - Fax:717-975-9781
Practice Address - Street 1:17910 TALBOT RD S
Practice Address - Street 2:#101
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055
Practice Address - Country:US
Practice Address - Phone:425-235-5588
Practice Address - Fax:425-687-9410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2008-02-29
Deactivation Date:2008-01-08
Deactivation Code:
Reactivation Date:2008-02-29
Provider Licenses
StateLicense IDTaxonomies
WA261QP2000X
261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation