Provider Demographics
NPI:1548264492
Name:PACIFIC PHYSICAL THERAPY INC.
Entity type:Organization
Organization Name:PACIFIC PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:707-964-1208
Mailing Address - Street 1:121 BOATYARD DR
Mailing Address - Street 2:STE A
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5751
Mailing Address - Country:US
Mailing Address - Phone:707-964-1208
Mailing Address - Fax:707-964-2269
Practice Address - Street 1:121 BOATYARD DR
Practice Address - Street 2:STE A
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5751
Practice Address - Country:US
Practice Address - Phone:707-964-1208
Practice Address - Fax:707-964-2269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPT001030Medicaid
CA=========OtherBLUE CROSS GROUP PROVIDER
CAZZZ24208ZMedicare PIN