Provider Demographics
NPI:1609087287
Name:SUSANVILLE THERAPY ATHLETIC REHABILITATION
Entity Type:Organization
Organization Name:SUSANVILLE THERAPY ATHLETIC REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:530-257-8989
Mailing Address - Street 1:711 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-4329
Mailing Address - Country:US
Mailing Address - Phone:530-257-8989
Mailing Address - Fax:530-257-4649
Practice Address - Street 1:711 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-4329
Practice Address - Country:US
Practice Address - Phone:530-257-8989
Practice Address - Fax:530-257-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12628225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ41322ZOtherBLUE SHIELD
CA00PT126280OtherBLUE CROSS
CA=========OtherTAX ID
CA0PT126280Medicare ID - Type Unspecified