Provider Demographics
NPI:1366521783
Name:VANDERBILT PHYSICAL THERAPY
Entity type:Organization
Organization Name:VANDERBILT PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANDERBILT
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:916-879-7867
Mailing Address - Street 1:2700 KLAMATH DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-5202
Mailing Address - Country:US
Mailing Address - Phone:916-879-7867
Mailing Address - Fax:916-435-4970
Practice Address - Street 1:107 S HARDING BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-3354
Practice Address - Country:US
Practice Address - Phone:916-879-7867
Practice Address - Fax:916-435-4970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0PT249582251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty