Provider Demographics
NPI:1477749315
Name:ALTA ORTHOPAEDIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ALTA ORTHOPAEDIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ALEN
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:805-963-9377
Mailing Address - Street 1:511 BATH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-3403
Mailing Address - Country:US
Mailing Address - Phone:805-963-9377
Mailing Address - Fax:805-962-2154
Practice Address - Street 1:511 BATH ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-3403
Practice Address - Country:US
Practice Address - Phone:805-963-9377
Practice Address - Fax:805-962-2154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12281261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT12281AMedicare PIN