Healthcare Provider Details

I. General information

NPI: 1497137384
Provider Name (Legal Business Name): OPTIMOTION PHYSICAL THERAPY SPORT AND SPINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1736 PICASSO AVE SUITE A
DAVIS CA
95618-0558
US

IV. Provider business mailing address

1736 PICASSO AVE SUITE A
DAVIS CA
95618-0558
US

V. Phone/Fax

Practice location:
  • Phone: 530-867-6679
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number30188
License Number StateCA

VIII. Authorized Official

Name: DR. AMY LING FONG
Title or Position: PRESIDENT
Credential: PT, DPT, OCS, SCS
Phone: 530-867-6679