Healthcare Provider Details

I. General information

NPI: 1104127554
Provider Name (Legal Business Name): BIOSPORT PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4341 SPYRES WAY
MODESTO CA
95356-9259
US

IV. Provider business mailing address

PO BOX 576751
MODESTO CA
95357-6751
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-7488
  • Fax: 209-522-7488
Mailing address:
  • Phone: 209-524-7488
  • Fax: 209-522-7488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number27941
License Number StateCA

VIII. Authorized Official

Name: DR. LEOVARDO CHAVEZ
Title or Position: PHYSICAL THERAPIST / PRESIDENT
Credential: MPT, DPT, ATC
Phone: 209-524-7488