1578531398 NPI number — ATHLETIC & INDUSTRIAL REHABILITATN PHYSICAL THERAPY INC A PROF CORP

Table of content: (NPI 1578531398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578531398 NPI number — ATHLETIC & INDUSTRIAL REHABILITATN PHYSICAL THERAPY INC A PROF CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATHLETIC & INDUSTRIAL REHABILITATN PHYSICAL THERAPY INC A PROF CORP
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:
AIR PHYSICAL THERAPY
Provider Other Organization Name Type Code:
5
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:
1578531398
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 GLASS LN STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95356-9287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-342-2300
Provider Business Mailing Address Fax Number:
209-524-4240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2116 E ORANGEBURG AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95355-3370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-529-1709
Provider Business Practice Location Address Fax Number:
209-572-2841
Provider Enumeration Date:
03/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLAUSSEN
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRES OF CORP
Authorized Official Telephone Number:
209-529-1709

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  PT8536 , 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)





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