Provider Demographics
NPI:1235210501
Name:EARLE, JAMES G (MPT, CSCS)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:G
Last Name:EARLE
Suffix:
Gender:M
Credentials:MPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 493396
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-3396
Mailing Address - Country:US
Mailing Address - Phone:530-221-9952
Mailing Address - Fax:530-221-9910
Practice Address - Street 1:5061 SHASTA DAM BLVD
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9405
Practice Address - Country:US
Practice Address - Phone:530-275-0777
Practice Address - Fax:530-275-8779
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23572225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0184300Medicaid
CAZZZ02253ZMedicare ID - Type Unspecified