Provider Demographics
NPI:1326527730
Name:STAC PHYSICAL THERAPY EMERYVILLE, INC.
Entity Type:Organization
Organization Name:STAC PHYSICAL THERAPY EMERYVILLE, INC.
Other - Org Name:EMERYVILLE SPORTS PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OR
Authorized Official - Middle Name:
Authorized Official - Last Name:NATIV
Authorized Official - Suffix:
Authorized Official - Credentials:PT, CSCS
Authorized Official - Phone:510-653-5151
Mailing Address - Street 1:2322 POWELL ST
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2322 POWELL ST
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1738
Practice Address - Country:US
Practice Address - Phone:626-825-3739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-08
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA339972251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty