Provider Demographics
NPI:1972520898
Name:CENTRAL VALLEY PHYSICAL THERAPY
Entity Type:Organization
Organization Name:CENTRAL VALLEY PHYSICAL THERAPY
Other - Org Name:CENTRAL VALLEY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARRIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:209-473-2383
Mailing Address - Street 1:1716 W HAMMER LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-2922
Mailing Address - Country:US
Mailing Address - Phone:209-473-2383
Mailing Address - Fax:209-473-1350
Practice Address - Street 1:1716 W HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2922
Practice Address - Country:US
Practice Address - Phone:209-473-2383
Practice Address - Fax:209-473-1350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT132010Medicare ID - Type Unspecified