Basic Information
Provider Information | |||||||||
NPI: | 1871666974 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | P.S.M.R.C., LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PENINSULA SPORTS MEDICINE AND REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2945 JUNIPERO SERRA BLVD | ||||||||
Address2: |   | ||||||||
City: | DALY CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 940142549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6507558830 | ||||||||
FaxNumber: | 6507558147 | ||||||||
Practice Location | |||||||||
Address1: | 2945 JUNIPERO SERRA BLVD | ||||||||
Address2: |   | ||||||||
City: | DALY CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 940142549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6507558830 | ||||||||
FaxNumber: | 6507558147 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2006 | ||||||||
LastUpdateDate: | 04/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAUENBUEHLER | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6507558830 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | GZ817A | 01 | CA | MEDICARE PTAN | OTHER |