Provider Demographics
NPI:1417933128
Name:BOB NYE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BOB NYE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:NYE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:805-735-8365
Mailing Address - Street 1:1101 E OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7096
Mailing Address - Country:US
Mailing Address - Phone:805-735-8365
Mailing Address - Fax:805-735-1604
Practice Address - Street 1:1101 E OCEAN AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7096
Practice Address - Country:US
Practice Address - Phone:805-735-8365
Practice Address - Fax:805-735-1604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0111600OtherMEDI-CAL
CAW15278Medicare ID - Type UnspecifiedGROUP NUMBER