Provider Demographics
NPI:1982630182
Name:GORDON DAVID MASON AND EMILY SUE MASON
Entity Type:Organization
Organization Name:GORDON DAVID MASON AND EMILY SUE MASON
Other - Org Name:MASON PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-682-4176
Mailing Address - Street 1:6840 INDIANA AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4298
Mailing Address - Country:US
Mailing Address - Phone:951-682-4176
Mailing Address - Fax:951-682-4188
Practice Address - Street 1:6840 INDIANA AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4298
Practice Address - Country:US
Practice Address - Phone:951-682-4176
Practice Address - Fax:951-682-4188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ66551ZOtherBLUE SHIELD
CAZZZ66551ZOtherBLUE SHIELD