Healthcare Provider Details

I. General information

NPI: 1811084676
Provider Name (Legal Business Name): GOLDEN BEAR PHYSICAL THERAPY SPORTS INJURY CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4318 SPYRES WAY
MODESTO CA
95356-9259
US

IV. Provider business mailing address

PO BOX 52219
PHOENIX AZ
85072-2219
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-0710
  • Fax: 209-622-4159
Mailing address:
  • Phone: 209-576-0888
  • Fax: 209-576-0913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BOBBY ISMAIL
Title or Position: CEO
Credential: DPT
Phone: 209-353-1988