Provider Demographics
NPI:1811084676
Name:GOLDEN BEAR PHYSICAL THERAPY SPORTS INJURY CENTER, INC
Entity type:Organization
Organization Name:GOLDEN BEAR PHYSICAL THERAPY SPORTS INJURY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:ISMAIL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:209-353-1988
Mailing Address - Street 1:PO BOX 52219
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2219
Mailing Address - Country:US
Mailing Address - Phone:209-576-0888
Mailing Address - Fax:209-576-0913
Practice Address - Street 1:4318 SPYRES WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9259
Practice Address - Country:US
Practice Address - Phone:209-576-0710
Practice Address - Fax:209-622-4159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03337ZMedicare PIN