1114909629 NPI number — GOLDEN STATE PHYSICAL THERAPY INC

Table of content: (NPI 1114909629)

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:
Provider Other Organization Name Type Code:
6
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:
09/11/2025
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: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XH1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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".