Healthcare Provider Details

I. General information

NPI: 1720117104
Provider Name (Legal Business Name): IVEY PHYSICAL THERAPY A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2007
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10565 BRUNSWICK RD SUITE 4
GRASS VALLEY CA
95945-9053
US

IV. Provider business mailing address

10565 BRUNSWICK RD SUITE 4
GRASS VALLEY CA
95945-9053
US

V. Phone/Fax

Practice location:
  • Phone: 530-273-4152
  • Fax: 530-273-4153
Mailing address:
  • Phone: 530-273-4152
  • Fax: 530-273-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT20829
License Number StateCA

VIII. Authorized Official

Name: KEVIN DALE IVEY
Title or Position: PRESIDENT
Credential:
Phone: 530-273-4152