Provider Demographics
NPI:1275258485
Name:EMERALD BAY PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:EMERALD BAY PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER/CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-314-3971
Mailing Address - Street 1:812 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6413
Mailing Address - Country:US
Mailing Address - Phone:530-542-2662
Mailing Address - Fax:530-542-2661
Practice Address - Street 1:812 EMERALD BAY RD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6413
Practice Address - Country:US
Practice Address - Phone:530-542-2662
Practice Address - Fax:530-542-2661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-10
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12524419OtherCAQH