Healthcare Provider Details

I. General information

NPI: 1861672958
Provider Name (Legal Business Name): PERSONAL EDGE PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7080 DONLON WAY #108
DUBLIN CA
94568-2787
US

IV. Provider business mailing address

7080 DONLON WAY #108
DUBLIN CA
94568-2787
US

V. Phone/Fax

Practice location:
  • Phone: 925-556-4310
  • Fax: 925-556-0375
Mailing address:
  • Phone: 925-556-4310
  • Fax: 925-556-0375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT 23848
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT 34053
License Number StateCA

VIII. Authorized Official

Name: GINA MARY VILLA
Title or Position: ADMIN. DIRECOR / SECRETARY
Credential:
Phone: 925-556-4310