Provider Demographics
NPI:1467429670
Name:PHYSIOCARE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PHYSIOCARE PHYSICAL THERAPY
Other - Org Name:VATLEY CARE PT SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ESTELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:559-225-1029
Mailing Address - Street 1:PO BOX 3124
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93278-3124
Mailing Address - Country:US
Mailing Address - Phone:559-225-1029
Mailing Address - Fax:559-225-1043
Practice Address - Street 1:3223 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726
Practice Address - Country:US
Practice Address - Phone:559-225-1029
Practice Address - Fax:559-225-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10890225100000X
CAPT32627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ09383ZOtherBLUE SHIELD
CAGPT001631Medicaid
CAZZZ09383ZOtherBLUE SHIELD