Provider Demographics
NPI:1043379282
Name:KING CITY PHYSICAL THERAPY APC
Entity Type:Organization
Organization Name:KING CITY PHYSICAL THERAPY APC
Other - Org Name:SUMMIT PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ESTRADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-227-4156
Mailing Address - Street 1:200 BROADWAY ST
Mailing Address - Street 2:STE 28
Mailing Address - City:KING CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93930-2865
Mailing Address - Country:US
Mailing Address - Phone:831-386-9710
Mailing Address - Fax:
Practice Address - Street 1:200 BROADWAY ST
Practice Address - Street 2:STE 28
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-2865
Practice Address - Country:US
Practice Address - Phone:831-386-9710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT06391261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06333ZOtherBLUE SHIELD OF CALIF
CAPT6391OtherBLUE CROSS OF CALIF
CAGPT001411Medicaid
CAPT6391OtherBLUE CROSS OF CALIF