Healthcare Provider Details

I. General information

NPI: 1548264492
Provider Name (Legal Business Name): PACIFIC PHYSICAL THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 BOATYARD DR STE A
FORT BRAGG CA
95437-5751
US

IV. Provider business mailing address

121 BOATYARD DR STE A
FORT BRAGG CA
95437-5751
US

V. Phone/Fax

Practice location:
  • Phone: 707-964-1208
  • Fax: 707-964-2269
Mailing address:
  • Phone: 707-964-1208
  • Fax: 707-964-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: TAMMY GAYLE PATRICK
Title or Position: PRESIDENT
Credential: RPT
Phone: 707-964-1208