1801272992 NPI number — PREMIUM PHYSICAL THERAPY INC

Table of content: (NPI 1801272992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801272992 NPI number — PREMIUM PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIUM 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:
1801272992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7471 N FRESNO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93720-2457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-436-6228
Provider Business Mailing Address Fax Number:
559-436-0500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 HERNDON AVE
Provider Second Line Business Practice Location Address:
STE. 102
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93611-6101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-321-8405
Provider Business Practice Location Address Fax Number:
559-900-7952
Provider Enumeration Date:
07/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BIGGERS
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
SHAWN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
559-321-8405

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)

  • Identifier: 261QP2000X . This is a "TAXONOMY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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