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NPI Code Detail

MEDICARE: CREEK SIDE ORTHOPEDIC

MEDICARE: CREEK SIDE ORTHOPEDIC
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
1225100000XPhysical Therapist1813761CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1ZZZ40093ZOTHERCABLUE SHIELD PIN

General Provider Information

NPI Number : 1295718831
Entity Type Code : Organization
Provider Name (Legal Business Name) : CREEK SIDE ORTHOPEDIC
Provider Business Mailing Address
First Line : 1545 HIGUERA ST
Second Line :
City : SAN LUIS OBISPO
State : CA
Zip : 93401-2917
Country : US
Telephone Number : 805-543-5633
Fax Number : 805-543-5990
Provider Business Practice Location Address
First Line : 1545 HIGUERA ST
Second Line :
City : SAN LUIS OBISPO
State : CA
Zip : 93401-2917
Country : US
Telephone Number : 805-543-5633
Fax Number : 805-543-5990
Authorized Official
Title or Position : PRESIDENT
Name : DONALD R. OLSON
Credential : R.P.T.
Telephone Number : 805-543-5633
Provider Enumeration Date : 11/29/2005
Last Update Date : 03/26/2015

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Directions to “CREEK SIDE ORTHOPEDIC ” Practice Location

Language Start Address Practice Location
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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