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General NPI Number Information
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NPI Number | 1366521783
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Entity Type | Organization
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Legal Business Name | VANDERBILT PHYSICAL THERAPY
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Dates
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Enumeration Date | 11/05/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 107 S HARDING BLVD
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City | ROSEVILLE
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State | CA
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Zip | 95678-3354
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Country | US
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Telephone | 916-879-7867
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Fax | 916-435-4970
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Provider Business Mailing Address
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Address Line | 2700 KLAMATH DR
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City | ROCKLIN
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State | CA
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Zip | 95765-5202
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Country | US
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Telephone | 916-879-7867
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Fax | 916-435-4970
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | JOHN J VANDERBILT JR.
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Credential | PT
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Telephone | 916-879-7867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 0PT24958
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License Number State | CA
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