Provider Demographics
NPI:1750443826
Name:MARK WARREN DUCKETT
Entity Type:Organization
Organization Name:MARK WARREN DUCKETT
Other - Org Name:MOUNTAIN VALLEY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:530-623-2570
Mailing Address - Street 1:PO BOX 2120
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96093-2120
Mailing Address - Country:US
Mailing Address - Phone:530-623-2570
Mailing Address - Fax:530-623-2573
Practice Address - Street 1:50 NUGGET LANE
Practice Address - Street 2:SUITE A
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093-2120
Practice Address - Country:US
Practice Address - Phone:530-623-2570
Practice Address - Fax:530-623-2573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT62720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0062720Medicaid
CAPT0062720Medicaid