1205882875 NPI number — OUTBACK PHYSIOTHERAPY CENTRE, INC.

Table of content: MS. CYNTHIA MARIE MELTON RN (NPI 1235491911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205882875 NPI number — OUTBACK PHYSIOTHERAPY CENTRE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUTBACK PHYSIOTHERAPY CENTRE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205882875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1189 W STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92373-8123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-307-9121
Provider Business Mailing Address Fax Number:
909-307-9161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1189 W STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDLANDS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92373-8123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-307-9121
Provider Business Practice Location Address Fax Number:
909-307-9161
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KUBOSE
Authorized Official First Name:
KRISTINE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
909-307-9121

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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