Basic Information
Provider Information
NPI: 1497788202
EntityType: 2
ReplacementNPI:  
OrganizationName: FOLSOM PHYSICAL THERAPY AND TRAINING CENTER
LastName:  
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Mailing Information
Address1: 115 NATOMA ST
Address2:  
City: FOLSOM
State: CA
PostalCode: 956302615
CountryCode: US
TelephoneNumber: 9163558500
FaxNumber: 9163558196
Practice Location
Address1: 115 NATOMA ST
Address2:  
City: FOLSOM
State: CA
PostalCode: 956302615
CountryCode: US
TelephoneNumber: 9163558500
FaxNumber: 9163558196
Other Information
ProviderEnumerationDate: 07/08/2006
LastUpdateDate: 12/02/2008
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: MCGONIGLE
AuthorizedOfficialFirstName: TIMOTHY
AuthorizedOfficialMiddleName: EUGENE
AuthorizedOfficialTitleorPosition: PHYSICAL THERAPIST, CO-OWNER
AuthorizedOfficialTelephone: 9163558500
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: P.T.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2251X0800X0603009CAY193400000X MULTIPLE SINGLE SPECIALTY GROUPRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic

ID Information
IDTypeStateIssuerDescription
ZZZ61124Z01CABLUE SHIELDOTHER


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