Provider Demographics
NPI:1811015639
Name:MARTHA FAIR WILLIAMS SPORTREHAB PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MARTHA FAIR WILLIAMS SPORTREHAB PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:FAIR
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PT MS
Authorized Official - Phone:707-447-9750
Mailing Address - Street 1:81 CERNON STREET
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-2803
Mailing Address - Country:US
Mailing Address - Phone:707-447-9750
Mailing Address - Fax:707-447-9220
Practice Address - Street 1:81 CERNON STREET
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-2803
Practice Address - Country:US
Practice Address - Phone:707-447-9750
Practice Address - Fax:707-447-9220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Z00000X, 224P00000X, 225100000X
CA9761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0097610Medicaid
CAPT0097610Medicaid