Provider Demographics
NPI:1346460417
Name:PAUL JOHNSON PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:PAUL JOHNSON PHYSICAL THERAPY, INC
Other - Org Name:STAR, SPORTS TRAINING AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-542-8313
Mailing Address - Street 1:3033 CLEVELAND AVE.
Mailing Address - Street 2:205
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403
Mailing Address - Country:US
Mailing Address - Phone:707-542-8313
Mailing Address - Fax:
Practice Address - Street 1:3033 CLEVELAND AVE.
Practice Address - Street 2:205
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403
Practice Address - Country:US
Practice Address - Phone:707-542-8313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64164ZOtherBLUESHIELD
CAZZZ64164ZOtherBLUESHIELD