Provider Demographics
NPI:1962593590
Name:FUQUA PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:FUQUA PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FUQUA
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:916-723-3372
Mailing Address - Street 1:6560 GREENBACK LANE #100
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621
Mailing Address - Country:US
Mailing Address - Phone:916-723-3372
Mailing Address - Fax:916-722-5098
Practice Address - Street 1:6560 GREENBACK LANE #100
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621
Practice Address - Country:US
Practice Address - Phone:916-723-3372
Practice Address - Fax:916-722-5098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ16561ZMedicare PIN