Provider Demographics
NPI:1659531838
Name:COTATI ROHNERT PARK PHYSICAL THERAPY
Entity Type:Organization
Organization Name:COTATI ROHNERT PARK PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICALTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:IDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WARNOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:707-795-1636
Mailing Address - Street 1:7840 OLD REDWOOD HWY
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-5106
Mailing Address - Country:US
Mailing Address - Phone:707-795-1636
Mailing Address - Fax:707-795-2273
Practice Address - Street 1:7840 OLD REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931
Practice Address - Country:US
Practice Address - Phone:707-795-1636
Practice Address - Fax:707-795-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT87892251G0304X, 2251S0007X, 2251X0800X, 2251X0800X
CAOT9022225XH1300X, 225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No225XH1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHuman FactorsGroup - Multi-Specialty
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT87890Medicaid
CA00PT87890Medicare PIN