Healthcare Provider Details

I. General information

NPI: 1053945337
Provider Name (Legal Business Name): DRAGON PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 MARSH RD
TIBURON CA
94920-2541
US

IV. Provider business mailing address

24 MARSH RD
TIBURON CA
94920-2541
US

V. Phone/Fax

Practice location:
  • Phone: 646-821-3390
  • Fax:
Mailing address:
  • Phone: 646-821-3390
  • Fax:

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: ASHLEY J MAK
Title or Position: OWNER/CEO
Credential: PT, DPT
Phone: 646-821-3390