Basic Information
| Provider Information | |||||||||
| NPI: | 1801272992 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIUM PHYSICAL THERAPY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7471 N FRESNO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937202457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594366228 | ||||||||
| FaxNumber: | 5594360500 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 HERNDON AVE | ||||||||
| Address2: | STE. 102 | ||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936116101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593218405 | ||||||||
| FaxNumber: | 5599007952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2015 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | BIGGERS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | SHAWN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5593218405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 261QP2000X | 01 | CA | TAXONOMY | OTHER |