1538201546 NPI number — SEBASTOPOL PHYSICAL THERAPY AND PILATES STUDIO

Table of content: CAROL ANN PEARSON CRNA (NPI 1457421174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538201546 NPI number — SEBASTOPOL PHYSICAL THERAPY AND PILATES STUDIO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEBASTOPOL PHYSICAL THERAPY AND PILATES STUDIO
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:
1538201546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 PLEASANT HILL AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEBASTOPOL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95472-3104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-829-3282
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 PLEASANT HILL AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEBASTOPOL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95472-3104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-829-3282
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
DONOVAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
707-829-3282

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT13313 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ07609Z . This is a "BLUE SHIELD PROVIDER NUMB" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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