Healthcare Provider Details

I. General information

NPI: 1225029630
Provider Name (Legal Business Name): ANDERSEN PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1917 COFFEE RD
MODESTO CA
95355-2704
US

IV. Provider business mailing address

PO BOX 576276
MODESTO CA
95357-6276
US

V. Phone/Fax

Practice location:
  • Phone: 209-549-4626
  • Fax: 209-549-4625
Mailing address:
  • Phone: 209-549-4626
  • Fax: 209-549-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number0134075
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: LYLE MELVIN ANDERSEN
Title or Position: CO OWNER
Credential: PT
Phone: 209-549-4626