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NPI Code Detail

MEDICARE: EMERALD BAY PHYSICAL THERAPY PC

MEDICARE: EMERALD BAY PHYSICAL THERAPY PC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208100000XPhysical Medicine & Rehabilitation Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
112524419OTHERCAQH

General Provider Information

NPI Number : 1275258485
Entity Type Code : Organization
Provider Name (Legal Business Name) : EMERALD BAY PHYSICAL THERAPY PC
Provider Business Mailing Address
First Line : 812 EMERALD BAY RD
Second Line :
City : SOUTH LAKE TAHOE
State : CA
Zip : 96150-6413
Country : US
Telephone Number : 530-542-2662
Fax Number : 530-542-2661
Provider Business Practice Location Address
First Line : 812 EMERALD BAY RD
Second Line :
City : SOUTH LAKE TAHOE
State : CA
Zip : 96150-6413
Country : US
Telephone Number : 530-542-2662
Fax Number : 530-542-2661
Authorized Official
Title or Position : BILLER/CREDENTIALING SPECIALIST
Name : STACEY A MULLINS
Credential :
Telephone Number : 530-314-3971
Provider Enumeration Date : 10/10/2022
Last Update Date : 12/28/2023

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1710961115 — RICHARD N ALEXANDER PT
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1134306137 — RICHARD N ALEXANDER
Practice Location Address:
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Practice Fax: 530-542-2661

Directions to “EMERALD BAY PHYSICAL THERAPY PC ” Practice Location

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