Provider Demographics
NPI:1487946273
Name:ROSEVILLE ORTHOPEDIC PHYSICAL THERAPY PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:ROSEVILLE ORTHOPEDIC PHYSICAL THERAPY PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-782-1217
Mailing Address - Street 1:151 N SUNRISE AVE
Mailing Address - Street 2:#1005
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2924
Mailing Address - Country:US
Mailing Address - Phone:916-782-1217
Mailing Address - Fax:916-782-7630
Practice Address - Street 1:151 N SUNRISE AVE
Practice Address - Street 2:#1005
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2924
Practice Address - Country:US
Practice Address - Phone:916-782-1217
Practice Address - Fax:916-782-7630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty