Healthcare Provider Details

I. General information

NPI: 1013152339
Provider Name (Legal Business Name): PINE MOUNTAIN THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18687 MAIN STREET
GROVELAND CA
95321
US

IV. Provider business mailing address

PO BOX 513
GROVELAND CA
95321-0513
US

V. Phone/Fax

Practice location:
  • Phone: 831-238-2357
  • Fax:
Mailing address:
  • Phone: 831-238-2357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number27935
License Number StateCA

VIII. Authorized Official

Name: JULIE DEEN TANAKA
Title or Position: OWNER
Credential: P.T.
Phone: 831-238-2357