Provider Demographics
NPI:1003021601
Name:SCOTT VALLEY PHYSICAL THERAPY AND FITNESS CENTER, PC
Entity Type:Organization
Organization Name:SCOTT VALLEY PHYSICAL THERAPY AND FITNESS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:KORCEK
Authorized Official - Suffix:
Authorized Official - Credentials:P T
Authorized Official - Phone:530-468-5528
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:FORT JONES
Mailing Address - State:CA
Mailing Address - Zip Code:96032-0217
Mailing Address - Country:US
Mailing Address - Phone:530-468-5528
Mailing Address - Fax:
Practice Address - Street 1:122 SCOTT RIVER RD
Practice Address - Street 2:
Practice Address - City:FORT JONES
Practice Address - State:CA
Practice Address - Zip Code:96032-9620
Practice Address - Country:US
Practice Address - Phone:530-468-5528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ50708YOtherBLUE SHIELD
CAZZZ05286ZMedicare PIN
CAZZZ50708YOtherBLUE SHIELD
CA6149060001Medicare NSC