Provider Demographics
NPI:1659688554
Name:SKY R. GOUDEY P T INC P S
Entity Type:Organization
Organization Name:SKY R. GOUDEY P T INC P S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SKY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOUDEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-533-2252
Mailing Address - Street 1:72840 HIGHWAY 111 STE A-150
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3324
Mailing Address - Country:US
Mailing Address - Phone:858-614-6332
Mailing Address - Fax:858-614-6332
Practice Address - Street 1:72840 HIGHWAY 111 STE A-150
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3324
Practice Address - Country:US
Practice Address - Phone:858-614-6332
Practice Address - Fax:858-614-6332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty