Healthcare Provider Details

I. General information

NPI: 1255376893
Provider Name (Legal Business Name): SHASTA LAKE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5061 SHASTA DAM BLVD
SHASTA LAKE CA
96019-9422
US

IV. Provider business mailing address

PO BOX 493396
REDDING CA
96049-3396
US

V. Phone/Fax

Practice location:
  • Phone: 530-275-0777
  • Fax: 530-275-8779
Mailing address:
  • Phone: 530-221-9952
  • Fax: 530-221-9554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00-0004
License Number StateCA

VIII. Authorized Official

Name: MR. DONALD ROY BAAS
Title or Position: CO-OWNER / PHYSICAL THERAPIST
Credential: P.T.
Phone: 530-221-9952