Provider Demographics
NPI:1336735687
Name:GOLD STAR PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:GOLD STAR PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAYNELLA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TIU
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:314-629-2150
Mailing Address - Street 1:2651 CRIMSON CANYON DR STE 120
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2651 CRIMSON CANYON DR STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0843
Practice Address - Country:US
Practice Address - Phone:314-629-2150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-21
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251C2600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistCardiopulmonaryGroup - Multi-Specialty