=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700958972
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DWIGHT A. PEACE PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 REGIS ST SUITE A
-----------------------------------------------------
City | TURLOCK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95382-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-632-9965
-----------------------------------------------------
Fax | 209-632-9966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 STANDIFORD AVE SUITE F
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-1159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-579-5628
-----------------------------------------------------
Fax | 209-579-5637
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DWIGHT ALAN PEACE
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 209-632-9965
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT14033
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------