Emerald Bay Physical Therapy PC

Primary specialty

Physical Medicine & Rehabilitation PhysicianTaxonomy code 208100000X

Legal business name

EMERALD BAY PHYSICAL THERAPY PC

Practice address

812 Emerald Bay Rd
South Lake Tahoe, CA 96150-6413

Phone

(530) 542-2662

Fax

(530) 542-2661

NPI assigned

Oct 10, 2022

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Stacey A Mullins

Title

Biller/Credentialing Specialist

Phone

(530) 314-3971

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jessica H Jones, PT

  • Physical Therapist
  • S Lake Tahoe, CA
  • NPI 1679853238
  Medicare reassignment Care Compare group NPD
• Nancy NG, PHYSICAL THERAPIST

  • Physical Therapist
  • South Lake Tahoe, CA
  • NPI 1255707618
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1665360000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1703721600000",
    "number": "1275258485",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "812 EMERALD BAY RD",
            "city": "SOUTH LAKE TAHOE",
            "state": "CA",
            "postal_code": "961506413",
            "telephone_number": "530-542-2662",
            "fax_number": "530-542-2661"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "812 EMERALD BAY RD",
            "city": "SOUTH LAKE TAHOE",
            "state": "CA",
            "postal_code": "961506413",
            "telephone_number": "530-542-2662",
            "fax_number": "530-542-2661"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EMERALD BAY PHYSICAL THERAPY PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-10-10",
        "last_updated": "2023-12-28",
        "certification_date": "2023-12-28",
        "status": "A",
        "authorized_official_last_name": "MULLINS",
        "authorized_official_first_name": "STACEY",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "BILLER/CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "530-314-3971"
    },
    "taxonomies": [
        {
            "code": "208100000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Medicine & Rehabilitation",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAQH",
            "identifier": "12524419",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• El Dorado County Probation Department
• Elevate Wellness and Acupuncture Center
• Elevated Fitness LLC
• Tiffany Renee' Ellis
• Emerald Bay Center for Women'S Health, Inc.
• Lars Douglas Ensign, MD
• Kyle Erkkila, PA-C
• Pollyanne Ertis, RDN
• Marc Estabrook
• Jeffrey Evans

• Physical Medicine & Rehabilitation Physician in South Lake Tahoe, CA
• Providers in South Lake Tahoe, CA by specialty
• Physical Medicine & Rehabilitation Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 28, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.