1114909629 NPI number — GOLDEN STATE PHYSICAL THERAPY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114909629 NPI number — GOLDEN STATE PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN STATE PHYSICAL THERAPY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SANDERSON PHYSICAL THERAPY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114909629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 612260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95161-2260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-325-2776
Provider Business Mailing Address Fax Number:
408-945-4011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
565 BRUNSWICK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRASS VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95945-9392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-273-4152
Provider Business Practice Location Address Fax Number:
530-273-4153
Provider Enumeration Date:
11/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LASSON
Authorized Official First Name:
ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
408-570-0510

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225XH1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 102476 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: ZZ08937Z . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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