Provider Demographics
NPI:1275633000
Name:TICE VALLEY PHYSICAL THERAPY AND SPORTS MEDICINE INC.
Entity Type:Organization
Organization Name:TICE VALLEY PHYSICAL THERAPY AND SPORTS MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:DENDINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-935-0510
Mailing Address - Street 1:1874 TICE VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595-2224
Mailing Address - Country:US
Mailing Address - Phone:925-935-0510
Mailing Address - Fax:925-935-0750
Practice Address - Street 1:1874 TICE VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595
Practice Address - Country:US
Practice Address - Phone:925-935-0510
Practice Address - Fax:925-935-0750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 21277261QP2000X
CAPT 19177261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ21402ZMedicare ID - Type Unspecified