1366769234 NPI number — GREAT BASIN PHYSICAL THERAPY AND PERFORMANCE CENTER

Table of content: (NPI 1366769234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366769234 NPI number — GREAT BASIN PHYSICAL THERAPY AND PERFORMANCE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT BASIN PHYSICAL THERAPY AND PERFORMANCE CENTER
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:
Provider Other Organization Name Type Code:
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:
1366769234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 34120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89533-4120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-747-5050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 COUNTY RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MINDEN
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89423-4464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-782-4466
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DATT
Authorized Official First Name:
ASHWIN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
831-238-5217

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2193 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2193 . This is a "BOARD OF PHYSICAL THERAPY EXAMINERS" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 34615 . This is a "PHYSICAL THERAPY BOARD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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