Provider Demographics
NPI:1366526121
Name:SORENSEN, ERIC SCOTT (PT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:SCOTT
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-2340
Mailing Address - Country:US
Mailing Address - Phone:209-369-3994
Mailing Address - Fax:
Practice Address - Street 1:1822 W KETTLEMAN LN
Practice Address - Street 2:STE 1
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4218
Practice Address - Country:US
Practice Address - Phone:209-368-1678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0PT14001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT140010Medicare ID - Type UnspecifiedPHYSICAL THERAPY
CAR24595Medicare UPIN