Provider Demographics
NPI:1619466166
Name:THAYER, JOHN CHARLES (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:THAYER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 CENTRAL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-4389
Mailing Address - Country:US
Mailing Address - Phone:707-839-5905
Mailing Address - Fax:
Practice Address - Street 1:1650 CENTRAL AVE STE A
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-4389
Practice Address - Country:US
Practice Address - Phone:707-839-5905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist