1275551988 NPI number — EAGLE PHYSICAL THERAPY OF HUNTINGTON BEACH

Table of content: (NPI 1275551988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275551988 NPI number — EAGLE PHYSICAL THERAPY OF HUNTINGTON BEACH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE PHYSICAL THERAPY OF HUNTINGTON BEACH
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:
1275551988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19891 BEACH BLVD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92648-3209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-536-9700
Provider Business Mailing Address Fax Number:
714-536-9701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19891 BEACH BLVD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92648-3209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-536-9700
Provider Business Practice Location Address Fax Number:
714-536-9701
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STROTHER
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
714-536-9700

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  13554 , 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: PT13554 . This is a "LEGACY PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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