=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003378324
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEYERS PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2019
-----------------------------------------------------
Last Update Date | 09/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2311 LAKE TAHOE BLVD STE 1
-----------------------------------------------------
City | SOUTH LAKE TAHOE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96150-7104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-721-3253
-----------------------------------------------------
Fax | 530-285-2002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 550275
-----------------------------------------------------
City | SOUTH LAKE TAHOE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96155-0275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-721-3253
-----------------------------------------------------
Fax | 530-285-2002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSICA MONALOY
-----------------------------------------------------
Credential | PT CIMT
-----------------------------------------------------
Telephone | 530-721-3253
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------