1417175175 NPI number — PROVIDENCE PHYSICAL THERAPY, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417175175 NPI number — PROVIDENCE PHYSICAL THERAPY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE PHYSICAL THERAPY, 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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417175175
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:
3550 E PHILADELPHIA ST
Provider Second Line Business Mailing Address:
SUITE # 155
Provider Business Mailing Address City Name:
ONTARIO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91761-2962
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-773-0022
Provider Business Mailing Address Fax Number:
866-672-8222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3550 E PHILADELPHIA ST
Provider Second Line Business Practice Location Address:
SUITE # 155
Provider Business Practice Location Address City Name:
ONTARIO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91761-2962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-773-0022
Provider Business Practice Location Address Fax Number:
866-672-8222
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AZIZ
Authorized Official First Name:
PETER
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DIRECTOR OF THERAPY
Authorized Official Telephone Number:
909-773-0022

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 15402 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: BL#67598 . This is a "BUSINESS LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com