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General NPI Number Information
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NPI Number | 1306121801
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Entity Type | Organization
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Legal Business Name | SUPPLEMENTAL HEALTH CARE
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Dates
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Enumeration Date | 10/15/2011
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Last Update Date | 10/15/2011
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Provider Practice Location Address
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Address Line | 2515 AUGUSTINE LN
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City | PLACERVILLE
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State | CA
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Zip | 95667
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Country | US
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Telephone | 530-409-7103
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Fax |
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Provider Business Mailing Address
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Address Line | 2515 AUGUSTINE LN
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City | PLACERVILLE
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State | CA
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Zip | 95667-7120
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Country | US
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Telephone | 530-409-7103
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | MR. BRIAN STAHL
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Credential | PHYSICAL THERAPIST
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Telephone | 530-409-7103
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 9135
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License Number State | CA
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