Provider Demographics
NPI:1861672958
Name:PERSONAL EDGE PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PERSONAL EDGE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN. DIRECOR / SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:VILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-556-4310
Mailing Address - Street 1:7080 DONLON WAY
Mailing Address - Street 2:#108
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-2787
Mailing Address - Country:US
Mailing Address - Phone:925-556-4310
Mailing Address - Fax:925-556-0375
Practice Address - Street 1:7080 DONLON WAY
Practice Address - Street 2:#108
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-2787
Practice Address - Country:US
Practice Address - Phone:925-556-4310
Practice Address - Fax:925-556-0375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 23848261QP2000X
CAPT 34053261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ23426ZOtherMEDICARE PTAN
CAZZZ64073ZOtherBLUE SHIELD ID