Healthcare Provider Details

I. General information

NPI: 1841669710
Provider Name (Legal Business Name): GOLDEN BEAR PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4318 SPYRES WAY
MODESTO CA
95356-9259
US

IV. Provider business mailing address

4318 SPYRES WAY
MODESTO CA
95356-9259
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-0888
  • Fax: 209-576-0913
Mailing address:
  • Phone: 209-576-0888
  • Fax: 209-576-0913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT11025
License Number StateCA

VIII. Authorized Official

Name: MR. NICOLAS KING
Title or Position: PHYSICAL THERAPIST ASSISTANT
Credential: PTA
Phone: 209-576-0888