Basic Information
| Provider Information | |||||||||
| NPI: | 1225029630 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANDERSEN PHYSICAL THERAPY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 576276 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953576276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095494626 | ||||||||
| FaxNumber: | 2095494625 | ||||||||
| Practice Location | |||||||||
| Address1: | 1917 COFFEE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095494626 | ||||||||
| FaxNumber: | 2095494625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 04/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSEN | ||||||||
| AuthorizedOfficialFirstName: | LYLE | ||||||||
| AuthorizedOfficialMiddleName: | MELVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | CO OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2095494626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 261QP2000X | 0134075 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | YYY48495Y | 01 | CA | BLUE SHIELD | OTHER |