Healthcare Provider Details

I. General information

NPI: 1265523609
Provider Name (Legal Business Name): OLYMPIC PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BLACKFIELD DR
TIBURON CA
94920-2053
US

IV. Provider business mailing address

1 BLACKFIELD DR
TIBURON CA
94920-2053
US

V. Phone/Fax

Practice location:
  • Phone: 415-383-6789
  • Fax: 415-383-6744
Mailing address:
  • Phone: 415-383-6789
  • Fax: 415-383-6744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT20057
License Number StateCA

VIII. Authorized Official

Name: JEFF HARBAND
Title or Position: CEO
Credential: P.T.
Phone: 415-383-6789