Provider Demographics
NPI:1003816547
Name:PORTERVILLE PHYSICAL THERAPY SPORTS & ORTHOPEDICS
Entity Type:Organization
Organization Name:PORTERVILLE PHYSICAL THERAPY SPORTS & ORTHOPEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:859-783-0515
Mailing Address - Street 1:112 N D ST
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-3621
Mailing Address - Country:US
Mailing Address - Phone:559-783-0515
Mailing Address - Fax:559-783-0516
Practice Address - Street 1:112 N D ST
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3621
Practice Address - Country:US
Practice Address - Phone:559-783-0515
Practice Address - Fax:559-783-0516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14678225100000X
CAPT14613225100000X
CAPT25023225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ34847ZOtherBLUE SHIELD
ZZZ34847ZOtherBLUE SHIELD