Provider Demographics
NPI:1639491558
Name:ACORN PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ACORN PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-795-3588
Mailing Address - Street 1:PO BOX 2834
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:CA
Mailing Address - Zip Code:95223-2834
Mailing Address - Country:US
Mailing Address - Phone:209-795-3588
Mailing Address - Fax:209-795-6785
Practice Address - Street 1:2075 HIGHWAY 4
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:CA
Practice Address - Zip Code:95223
Practice Address - Country:US
Practice Address - Phone:209-795-3588
Practice Address - Fax:209-795-6785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9740261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT97400Medicare PIN