Basic Information
| Provider Information | |||||||||
| NPI: | 1992787477 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAMPUS COMMONS PHYSICAL THERAPY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 UNIVERSITY AVE STE 185 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958256739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169271333 | ||||||||
| FaxNumber: | 9169271586 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 UNIVERSITY AVE STE 185 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958256739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169271333 | ||||||||
| FaxNumber: | 9169271586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 11/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | EDDY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9169271333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ03086Z | 01 | BLUE SHIELD | OTHER | 197554800 | 01 | DOL | OTHER | DA1522 | 01 | CA | RAILROAD | OTHER | 5318800 | 01 | CA | CIGNA | OTHER |