Provider Demographics
NPI:1629238191
Name:PREMIER SPORTS MEDICINE AND PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PREMIER SPORTS MEDICINE AND PHYSICAL THERAPY
Other - Org Name:PREMIER PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-457-1800
Mailing Address - Street 1:PO BOX 3751
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95063-3751
Mailing Address - Country:US
Mailing Address - Phone:831-457-1800
Mailing Address - Fax:831-457-1802
Practice Address - Street 1:1003 RIVER ST
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1754
Practice Address - Country:US
Practice Address - Phone:831-457-1800
Practice Address - Fax:831-457-1802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25727261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAO096ZOtherPTAN