Provider Demographics
NPI:1578640124
Name:WOODLAND CREEK PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:WOODLAND CREEK PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:O
Authorized Official - Last Name:ENSIGN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, JSCC
Authorized Official - Phone:360-412-1367
Mailing Address - Street 1:5205 CORPORATE CENTER CT SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5901
Mailing Address - Country:US
Mailing Address - Phone:360-412-1368
Mailing Address - Fax:360-412-1391
Practice Address - Street 1:5205 CORPORATE CENTER CT SE
Practice Address - Street 2:SUITE C
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5901
Practice Address - Country:US
Practice Address - Phone:360-412-1367
Practice Address - Fax:360-412-1391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602 027 552174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7102437Medicaid
WAP31049Medicare UPIN
WA7102437Medicaid
WAAB21484Medicare UPIN
WAP31049Medicare PIN