1487651097 NPI number — BODYBASICS PHYSICAL THERAPY, INC.

Table of content: (NPI 1487651097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487651097 NPI number — BODYBASICS PHYSICAL THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BODYBASICS 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:
6
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:
1487651097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2275 S MAIN ST STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92882-5303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-273-7742
Provider Business Mailing Address Fax Number:
951-273-7747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3178 HAMNER AVE STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92860-1936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-736-5646
Provider Business Practice Location Address Fax Number:
951-736-5694
Provider Enumeration Date:
06/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HUNSAKER
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
951-736-5646

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , 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: ZZZ09067Z . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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