Provider Demographics
NPI:1306904594
Name:GRANITE BAY PHYSICAL THERAPY
Entity type:Organization
Organization Name:GRANITE BAY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HEADRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:916-791-5011
Mailing Address - Street 1:6910 DOUGLAS BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-6276
Mailing Address - Country:US
Mailing Address - Phone:916-791-5011
Mailing Address - Fax:916-791-3211
Practice Address - Street 1:6910 DOUGLAS BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-6276
Practice Address - Country:US
Practice Address - Phone:916-791-5011
Practice Address - Fax:916-791-3211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATBDMedicare ID - Type UnspecifiedIN PROCESS