Provider Demographics
NPI:1497137384
Name:OPTIMOTION PHYSICAL THERAPY SPORT AND SPINE, INC.
Entity Type:Organization
Organization Name:OPTIMOTION PHYSICAL THERAPY SPORT AND SPINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LING
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS, SCS
Authorized Official - Phone:530-867-6679
Mailing Address - Street 1:1736 PICASSO AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-0558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1736 PICASSO AVE
Practice Address - Street 2:SUITE A
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-0558
Practice Address - Country:US
Practice Address - Phone:530-867-6679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30188261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy