Provider Demographics
NPI:1902198765
Name:DEWITT PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:DEWITT PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:831-475-2565
Mailing Address - Street 1:4125 PORTOLA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-4525
Mailing Address - Country:US
Mailing Address - Phone:831-475-2565
Mailing Address - Fax:831-475-2572
Practice Address - Street 1:4125 PORTOLA DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-4525
Practice Address - Country:US
Practice Address - Phone:831-475-2565
Practice Address - Fax:831-475-2572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30137261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy