Basic Information
| Provider Information | |||||||||
| NPI: | 1750372116 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PROCTOR | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 529 | ||||||||
| Address2: | |||||||||
| City: | ZEPHYR COVE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894480529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7755888938 | ||||||||
| FaxNumber: | 7755888930 | ||||||||
| Practice Location | |||||||||
| Address1: | 1139 3RD ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961503465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305413100 | ||||||||
| FaxNumber: | 5305413016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 11/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT22738 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1203 | NV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00211696 | 01 | CA | MEDICARE RAILROAD | OTHER | CC7486 | 01 | NV | BCBS | OTHER | PT0227380 | 01 | CA | MEDI-CAL | OTHER |