Provider Demographics
NPI:1720117104
Name:IVEY PHYSICAL THERAPY A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:IVEY PHYSICAL THERAPY A PROFESSIONAL CORPORATION
Other - Org Name:SANDERSON IVEY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:IVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-273-4152
Mailing Address - Street 1:10565 BRUNSWICK RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9053
Mailing Address - Country:US
Mailing Address - Phone:530-273-4152
Mailing Address - Fax:530-273-4153
Practice Address - Street 1:10565 BRUNSWICK RD
Practice Address - Street 2:SUITE 4
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9053
Practice Address - Country:US
Practice Address - Phone:530-273-4152
Practice Address - Fax:530-273-4153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-03
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20829261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy