Provider Demographics
NPI:1972667947
Name:MITCHELL KAUK
Entity Type:Organization
Organization Name:MITCHELL KAUK
Other - Org Name:PETALUMA ORTHOPAEDIC & SPORTS THERAPY (P.O.S.T.)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUK
Authorized Official - Suffix:
Authorized Official - Credentials:PT OCS
Authorized Official - Phone:707-762-7678
Mailing Address - Street 1:224A WELLER ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3136
Mailing Address - Country:US
Mailing Address - Phone:707-762-7678
Mailing Address - Fax:707-762-7679
Practice Address - Street 1:224A WELLER ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3136
Practice Address - Country:US
Practice Address - Phone:707-762-7678
Practice Address - Fax:707-762-7679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT109592251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPT001480Medicaid
CAZZZ22117ZMedicare PIN