Provider Demographics
NPI:1952300782
Name:WILDWOOD PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:WILDWOOD PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:LEDUC
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:530-432-9660
Mailing Address - Street 1:11392 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946-9001
Mailing Address - Country:US
Mailing Address - Phone:530-432-9660
Mailing Address - Fax:530-432-9663
Practice Address - Street 1:11392 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:PENN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95946-9001
Practice Address - Country:US
Practice Address - Phone:530-432-9660
Practice Address - Fax:530-432-9663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy