Provider Demographics
NPI:1093945230
Name:NOVATO BACK CARE AND SPORTS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:NOVATO BACK CARE AND SPORTS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, OCS
Authorized Official - Phone:415-898-1311
Mailing Address - Street 1:165 ROWLAND WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-5038
Mailing Address - Country:US
Mailing Address - Phone:415-898-1311
Mailing Address - Fax:415-897-0741
Practice Address - Street 1:165 ROWLAND WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5038
Practice Address - Country:US
Practice Address - Phone:415-898-1311
Practice Address - Fax:415-897-0741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ17635ZOtherMEDICARE PTAN