Provider Demographics
NPI:1225029630
Name:ANDERSEN PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:ANDERSEN PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:209-549-4626
Mailing Address - Street 1:PO BOX 576276
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-6276
Mailing Address - Country:US
Mailing Address - Phone:209-549-4626
Mailing Address - Fax:209-549-4625
Practice Address - Street 1:1917 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2704
Practice Address - Country:US
Practice Address - Phone:209-549-4626
Practice Address - Fax:209-549-4625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 261QP2000X
CA0134075261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY48495YOtherBLUE SHIELD
CA4185520001Medicare NSC
CA4185520002Medicare NSC
CAYYY48495YMedicare PIN
CAZZZ20154ZMedicare PIN
CAYYY48495YOtherBLUE SHIELD
YYY48495YMedicare PIN