Basic Information
| Provider Information | |||||||||
| NPI: | 1316979800 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TOKHEIM CORBETT PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1191 E YOSEMITE AVE | ||||||||
| Address2: | STE. A | ||||||||
| City: | MANTECA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953365011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098249888 | ||||||||
| FaxNumber: | 2098249469 | ||||||||
| Practice Location | |||||||||
| Address1: | 1191 E YOSEMITE AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | MANTECA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953365011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095795628 | ||||||||
| FaxNumber: | 2095795637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 02/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | CORBETT | ||||||||
| AuthorizedOfficialFirstName: | HAL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2098249888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ07820Z | 01 | CA | BLUE SHIELD | OTHER | DC0745 | 01 | CA | RAILROAD MEDICARE | OTHER |