MEDICARE: GRANITE BAY 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	PT27707	CA

General Provider Information

NPI Number	:	1306904594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANITE BAY PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	6910 DOUGLAS BLVD
Second Line	:	SUITE D
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-6276
Country	:	US
Telephone Number	:	916-791-5011
Fax Number	:	916-791-3211

Provider Business Practice Location Address
First Line	:	6910 DOUGLAS BLVD
Second Line	:	SUITE D
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-6276
Country	:	US
Telephone Number	:	916-791-5011
Fax Number	:	916-791-3211

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTOPHER HEADRICK
Credential	:	DPT
Telephone Number	:	916-791-5011

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	08/22/2020

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Directions to “GRANITE BAY PHYSICAL THERAPY ” Practice Location

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