MEDICARE: SHASTA LAKE PHYSICAL THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	00-0004	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255376893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHASTA LAKE PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	PO BOX 493396
Second Line	:
City	:	REDDING
State	:	CA
Zip	:	96049-3396
Country	:	US
Telephone Number	:	530-221-9952
Fax Number	:	530-221-9554

Provider Business Practice Location Address
First Line	:	5061 SHASTA DAM BLVD
Second Line	:
City	:	SHASTA LAKE
State	:	CA
Zip	:	96019-9422
Country	:	US
Telephone Number	:	530-275-0777
Fax Number	:	530-275-8779

Authorized Official
Title or Position	:	CO-OWNER / PHYSICAL THERAPIST
Name	:	MR. DONALD ROY BAAS
Credential	:	P.T.
Telephone Number	:	530-221-9952

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	02/25/2009

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Directions to “SHASTA LAKE PHYSICAL THERAPY ” Practice Location

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