Provider Demographics
NPI:1518050442
Name:PHYSICAL THERAPY AT THE HEALTH CLUB
Entity Type:Organization
Organization Name:PHYSICAL THERAPY AT THE HEALTH CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER OF BUSINESS
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BLENNE
Authorized Official - Last Name:HASSETT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:707-468-3844
Mailing Address - Street 1:3101 SOUTH STATE STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482
Mailing Address - Country:US
Mailing Address - Phone:707-468-3844
Mailing Address - Fax:707-468-5001
Practice Address - Street 1:3101 SOUTH STATE STREET
Practice Address - Street 2:SUITE A
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482
Practice Address - Country:US
Practice Address - Phone:707-468-3844
Practice Address - Fax:707-468-5001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT126590OtherMEDICARE
CA00PT13810Medicare ID - Type Unspecified