Provider Demographics
NPI:1649255605
Name:THER-A-CON PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:THER-A-CON PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTIE
Authorized Official - Middle Name:JOHANNA
Authorized Official - Last Name:VAN WERKUM-GLIDDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:707-445-9150
Mailing Address - Street 1:2103 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3323
Mailing Address - Country:US
Mailing Address - Phone:707-445-9150
Mailing Address - Fax:707-444-1372
Practice Address - Street 1:2103 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3323
Practice Address - Country:US
Practice Address - Phone:707-445-9150
Practice Address - Fax:707-444-1372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
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
X50523Medicare UPIN
ZZZ27928ZMedicare ID - Type Unspecified