Basic Information
| Provider Information | |||||||||
| NPI: | 1699779140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYSPORT, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 987 UNIVERSITY AVE | ||||||||
| Address2: | STE 12 | ||||||||
| City: | LOS GATOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950327640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083957300 | ||||||||
| FaxNumber: | 4083957350 | ||||||||
| Practice Location | |||||||||
| Address1: | 14675 WINCHESTER BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS GATOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950321816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083958851 | ||||||||
| FaxNumber: | 4083958841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 06/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | EMERY | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, CFO | ||||||||
| AuthorizedOfficialTelephone: | 4083957300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT24147 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.