Provider Demographics
NPI:1295905321
Name:HOLLISTER PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:HOLLISTER PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LEWELLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:831-636-3392
Mailing Address - Street 1:6775 DUNNVILLE WAY
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-9241
Mailing Address - Country:US
Mailing Address - Phone:831-636-3392
Mailing Address - Fax:831-636-3393
Practice Address - Street 1:321 SAN FELIPE RD STE 16
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-3035
Practice Address - Country:US
Practice Address - Phone:831-636-3392
Practice Address - Fax:831-636-3393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT213640261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT213640Medicare PIN