Provider Demographics
NPI:1740894005
Name:PHYSICAL EDGE SPECIALTY SERVICES
Entity type:Organization
Organization Name:PHYSICAL EDGE SPECIALTY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-753-9011
Mailing Address - Street 1:1460 DREW AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4856
Mailing Address - Country:US
Mailing Address - Phone:530-753-9011
Mailing Address - Fax:530-753-9021
Practice Address - Street 1:1460 DREW AVE STE 200
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-4856
Practice Address - Country:US
Practice Address - Phone:530-753-9011
Practice Address - Fax:530-753-9021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty