=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053022467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRANDE MOFFATT PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2022
-----------------------------------------------------
Last Update Date | 12/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2701 OLD EUREKA WAY STE 1K
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96001-0228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-242-1728
-----------------------------------------------------
Fax | 530-242-1768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2701 OLD EUREKA WAY STE 1K
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96001-0228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-242-1728
-----------------------------------------------------
Fax | 530-242-1768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | BRANDE MOFFATT
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 530-242-1728
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------