1497593602 NPI number — SHEPARDSON PHYSICAL THERAPY CORPORATION

Table of content: (NPI 1497593602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497593602 NPI number — SHEPARDSON PHYSICAL THERAPY CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHEPARDSON PHYSICAL THERAPY CORPORATION
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:
1497593602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
952 KENNEDY DR APT B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPITOLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95010-2372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-999-0880
Provider Business Mailing Address Fax Number:
831-401-2398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4630 SOQUEL DR STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOQUEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95073-2180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-999-0880
Provider Business Practice Location Address Fax Number:
831-401-2398
Provider Enumeration Date:
07/20/2024

Additional Information

Authorized Official

Authorized Official Last Name:
SHEPARDSON
Authorized Official First Name:
JASON
Authorized Official Middle Name:
OLIVER
Authorized Official Title or Position:
DOCTOR OF PHYSICAL THERAPY
Authorized Official Telephone Number:
831-999-0880

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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