Provider Demographics
NPI:1487859864
Name:COUNTY OF TUOLUMNE
Entity Type:Organization
Organization Name:COUNTY OF TUOLUMNE
Other - Org Name:GROVELAND PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COUNTY ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEDRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-533-5511
Mailing Address - Street 1:PO BOX 4805
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370
Mailing Address - Country:US
Mailing Address - Phone:209-533-6874
Mailing Address - Fax:209-532-6982
Practice Address - Street 1:18687 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:CA
Practice Address - Zip Code:95321
Practice Address - Country:US
Practice Address - Phone:209-962-4035
Practice Address - Fax:209-962-5399
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF TUOLUMNE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-18
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CA261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain