=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114063153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL THERAPY OF LOS GATOS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15047 LOS GATOS BOULEVARD SUITE 180
-----------------------------------------------------
City | LOS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95032-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-358-6505
-----------------------------------------------------
Fax | 408-358-6404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15047 LOS GATOS BOULEVARD SUITE 180
-----------------------------------------------------
City | LOS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95032-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-358-6505
-----------------------------------------------------
Fax | 408-358-6404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT CEO
-----------------------------------------------------
Name | MR. ROBERT IRWIN NABER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 408-358-6505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT12257
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------