=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881064418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH COAST REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2015
-----------------------------------------------------
Last Update Date | 09/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 COTTONWOOD ST
-----------------------------------------------------
City | WOODLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95695-3614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-387-9431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 724 COTTONWOOD ST APT 221
-----------------------------------------------------
City | WOODLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95695-4341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-387-9431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL SCATES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 855-999-7342
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 41179
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------