Provider Demographics
NPI:1578758827
Name:STAR PHYSICAL THERAPY OF SANTA MARIA, INC.
Entity Type:Organization
Organization Name:STAR PHYSICAL THERAPY OF SANTA MARIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WAYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:951-966-6555
Mailing Address - Street 1:1152 VIA VERDE
Mailing Address - Street 2:134
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4401
Mailing Address - Country:US
Mailing Address - Phone:626-974-5665
Mailing Address - Fax:
Practice Address - Street 1:2342 PROFESSIONAL PKWY
Practice Address - Street 2:110
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1630
Practice Address - Country:US
Practice Address - Phone:805-614-0400
Practice Address - Fax:805-614-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ50346YOtherBLUE SHIELD OF CALIFORNIA
ZZZ50346YOtherBLUE SHIELD OF CALIFORNIA