Provider Demographics
NPI:1053342709
Name:JERRY'S PHYSICAL THERAPY CLINIC, INC.
Entity type:Organization
Organization Name:JERRY'S PHYSICAL THERAPY CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:GRZECHOWIAK
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:510-724-7600
Mailing Address - Street 1:1320 TARA HILLS DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2532
Mailing Address - Country:US
Mailing Address - Phone:510-724-7600
Mailing Address - Fax:510-724-8080
Practice Address - Street 1:1320 TARA HILLS DR
Practice Address - Street 2:SUITE D
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2532
Practice Address - Country:US
Practice Address - Phone:510-724-7600
Practice Address - Fax:510-724-8080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6872261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADG5790OtherRAILROAD MEDICARE GRP.#
CAZZZ06174ZOtherMEDICARE GROUP PTAN
CAZZZ55467ZOtherBLUESHIELD PROVIDER#