Provider Demographics
NPI:1679563670
Name:NEUROSPORT REHABILITATION ASSOCIATES
Entity type:Organization
Organization Name:NEUROSPORT REHABILITATION ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-608-3614
Mailing Address - Street 1:2296 COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5315
Mailing Address - Country:US
Mailing Address - Phone:510-797-9299
Mailing Address - Fax:
Practice Address - Street 1:3905 BEACON AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1405
Practice Address - Country:US
Practice Address - Phone:510-792-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ19979ZOtherBLUE SHIELD ID
CAZZZ26890ZMedicare ID - Type UnspecifiedMEDICARE ID #