Healthcare Provider Details

I. General information

NPI: 1316930076
Provider Name (Legal Business Name): BAY AREA SPINE & SPORT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CLEVELAND AVE SUITE B
SANTA ROSA CA
95401-4297
US

IV. Provider business mailing address

3444 KEARNY VILLA RD SUITE 200
SAN DIEGO CA
92123-1959
US

V. Phone/Fax

Practice location:
  • Phone: 707-526-4180
  • Fax: 707-526-4152
Mailing address:
  • Phone: 888-208-8526
  • Fax: 858-751-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOE L. VERNA
Title or Position: CHIEF OPERATING OFFICER
Credential: DC
Phone: 888-208-8526