Provider Demographics
NPI:1861579179
Name:WELLSPRING PHYSICAL THERAPY & PILATESSTUDIO, INC.
Entity type:Organization
Organization Name:WELLSPRING PHYSICAL THERAPY & PILATESSTUDIO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:707-942-8094
Mailing Address - Street 1:1338 B LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CALISTOGA
Mailing Address - State:CA
Mailing Address - Zip Code:94515-1209
Mailing Address - Country:US
Mailing Address - Phone:707-942-8094
Mailing Address - Fax:707-942-8096
Practice Address - Street 1:1338 B LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1209
Practice Address - Country:US
Practice Address - Phone:707-942-8094
Practice Address - Fax:707-942-8096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01855ZMedicare PIN