Provider Demographics
NPI:1417098070
Name:MT. SHASTA PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:MT. SHASTA PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-926-6010
Mailing Address - Street 1:633 LASSEN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-9002
Mailing Address - Country:US
Mailing Address - Phone:530-926-6010
Mailing Address - Fax:530-926-6909
Practice Address - Street 1:633 LASSEN LN
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-9002
Practice Address - Country:US
Practice Address - Phone:530-926-6010
Practice Address - Fax:530-926-6909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2015-04-22
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
CA056623Medicare ID - Type Unspecified