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General NPI Number Information
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NPI Number | 1639195761
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Entity Type | Organization
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Legal Business Name | SPORTS & WELLNESS PHYSICAL THERAPY, INC.
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Dates
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Enumeration Date | 07/14/2006
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Last Update Date | 09/13/2016
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Provider Practice Location Address
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Address Line | 3440 S HIGUERA ST STE 120
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-7393
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Country | US
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Telephone | 805-439-2159
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Fax | 805-439-2160
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Provider Business Mailing Address
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Address Line | PO BOX 3070
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City | SHELL BEACH
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State | CA
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Zip | 93448-3070
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Country | US
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Telephone | 805-439-2159
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICAL THERAPIST
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Name | DOUGLAS BRENT JOHNSON
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Credential | R.P.T.
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Telephone | 805-439-2159
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT14568
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License Number State | CA
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