Provider Demographics
NPI:1417164328
Name:CALIFORNIA ORTHOPEDIC & SPORTS THERAPY REHABILITATION SERVICES, INC.
Entity Type:Organization
Organization Name:CALIFORNIA ORTHOPEDIC & SPORTS THERAPY REHABILITATION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:VAN DYKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:831-462-1212
Mailing Address - Street 1:6193 SOQUEL DR
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-3116
Mailing Address - Country:US
Mailing Address - Phone:831-462-1212
Mailing Address - Fax:831-462-1221
Practice Address - Street 1:6193 SOQUEL DR
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3116
Practice Address - Country:US
Practice Address - Phone:831-462-1212
Practice Address - Fax:831-462-1221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT131812251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABG020Medicare PIN