NPIMap

Organization Active NPI

Pine Lake Physical Therapy & Sports Rehab, P.S.

  • Orthopedic Physical Therapist
  • Sammamish, WA
National Provider Identifier
1356471684
Registry record updated Mar 19, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Orthopedic Physical TherapistTaxonomy code 2251X0800X
License
PT00003047 Issued in WA
Legal business name
PINE LAKE PHYSICAL THERAPY & SPORTS REHAB, P.S.
Practice address
2850 228TH Ave SE
Suite B
Sammamish, WA 98075-9301
Phone
(425) 391-4488
Fax
(425) 391-8287
NPI assigned
Mar 6, 2007
Last updated
Mar 19, 2009By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 19, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Ronald Dean Enyeart, P.T.NPI 1487645891
Title
Owner
Phone
(425) 391-4488

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Orthopedic Physical Therapist 2251X0800X PT00003047 WA Primary

Addresses

Primary practice location

2850 228TH Ave SE
Suite B
Sammamish, WA 98075-9301

Mailing address

2850 228TH Ave SE
Suite B
Sammamish, WA 98075-9301
Phone (425) 391-4488

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040514000018 WA Part B Supplier - Clinic/Group Practice 1951391762 Receives reassigned benefits from 5 practitioners
Practice locations: Sammamish, WA

National Provider Directory

National Provider Directory

Locations

2850 228th Ave SE
Sammamish, WA 98075
Phone (425) 391-4488

2850 228th Ave SE
Ste B
Sammamish, WA 98075
Phone (425) 391-4488

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173139200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1237420800000",
    "number": "1356471684",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2850 228TH AVE SE",
            "address_2": "SUITE B",
            "city": "SAMMAMISH",
            "state": "WA",
            "postal_code": "980759301",
            "telephone_number": "425-391-4488",
            "fax_number": "425-391-8287"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2850 228TH AVE SE",
            "address_2": "SUITE B",
            "city": "SAMMAMISH",
            "state": "WA",
            "postal_code": "980759301",
            "telephone_number": "425-391-4488",
            "fax_number": "425-391-8287"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PINE LAKE PHYSICAL THERAPY & SPORTS REHAB, P.S.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-06",
        "last_updated": "2009-03-19",
        "status": "A",
        "authorized_official_last_name": "ENYEART",
        "authorized_official_first_name": "RONALD",
        "authorized_official_middle_name": "DEAN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "425-391-4488",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "P.T."
    },
    "taxonomies": [
        {
            "code": "2251X0800X",
            "taxonomy_group": "",
            "desc": "Physical Therapist, Orthopedic",
            "state": "WA",
            "license": "PT00003047",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Sammamish, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 19, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.