=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881999811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIMBERLAKE PHYSICAL THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2011
-----------------------------------------------------
Last Update Date | 01/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7551 TIMBERLAKE WAY SUITE 200
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95823-5420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-691-0446
-----------------------------------------------------
Fax | 916-691-9146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 232330
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95823-0422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-691-0446
-----------------------------------------------------
Fax | 916-691-9146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. CAROLYN T. PERETTI
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 916-691-0446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT51170
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------