Provider Demographics
NPI:1689880809
Name:SERVICE FIRST OF NORTHERN CALIFORNIA
Entity Type:Organization
Organization Name:SERVICE FIRST OF NORTHERN CALIFORNIA
Other - Org Name:AQUATIC THERAPY & WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:209-644-6300
Mailing Address - Street 1:102 W BIANCHI RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-7132
Mailing Address - Country:US
Mailing Address - Phone:209-644-6300
Mailing Address - Fax:209-951-0427
Practice Address - Street 1:102 W BIANCHI RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-7132
Practice Address - Country:US
Practice Address - Phone:209-644-6300
Practice Address - Fax:209-951-0427
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SERVICE FIRST OF NORTHERN CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-15
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0350000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA556587Medicare Oscar/Certification