1639443690 NPI number — LURIE PHYSICAL THERAPY PC

Table of content: (NPI 1639443690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639443690 NPI number — LURIE PHYSICAL THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LURIE PHYSICAL THERAPY PC
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:
1639443690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29139 FOUNTAINWOOD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AGOURA HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91301-1664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-250-3415
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17071 VENTURA BLVD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91316-4130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-250-3415
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LURIE
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
818-232-4884

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  37259 , 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: GG413A . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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