1881928893 NPI number — STONEMOUNTAIN PHYSICAL THERAPY

Table of content: (NPI 1881928893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881928893 NPI number — STONEMOUNTAIN PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONEMOUNTAIN PHYSICAL THERAPY
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:
1881928893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21628 GOLDEN STAR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEHACHAPI
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93561-8607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-823-8101
Provider Business Mailing Address Fax Number:
661-823-8108

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21628 GOLDEN STAR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEHACHAPI
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93561-8607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-823-8101
Provider Business Practice Location Address Fax Number:
661-823-8108
Provider Enumeration Date:
09/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
STEINBERG
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
661-823-8101

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  PT3215 , 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: BU979Z . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1396918504 . This is a "INDIVIDUAL MEDICARE NPI" identifier . This identifiers is of the category "OTHER".




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