Provider Demographics
NPI:1578847257
Name:PROFESSIONAL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PROFESSIONAL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.T. / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:209-392-8830
Mailing Address - Street 1:2138 MARGUERITE ST
Mailing Address - Street 2:
Mailing Address - City:DOS PALOS
Mailing Address - State:CA
Mailing Address - Zip Code:93620-2351
Mailing Address - Country:US
Mailing Address - Phone:209-392-8830
Mailing Address - Fax:209-392-8830
Practice Address - Street 1:2138 MARGUERITE ST
Practice Address - Street 2:
Practice Address - City:DOS PALOS
Practice Address - State:CA
Practice Address - Zip Code:93620-2351
Practice Address - Country:US
Practice Address - Phone:209-392-8830
Practice Address - Fax:209-392-8830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT18659261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT186590OtherMEDICARE PROVIDER #