1639195761 NPI number — SPORTS & WELLNESS PHYSICAL THERAPY, INC.

Table of content: (NPI 1639195761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639195761 NPI number — SPORTS & WELLNESS PHYSICAL THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS & WELLNESS 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:
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:
1639195761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELL BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93448-3070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-439-2159
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3440 S HIGUERA ST STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-7393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-439-2159
Provider Business Practice Location Address Fax Number:
805-439-2160
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
BRENT
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
805-439-2159

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT14568 , 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: GPT001450 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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