Provider Demographics
NPI:1043585045
Name:ADVANCED HEALTH REHAB
Entity Type:Organization
Organization Name:ADVANCED HEALTH REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-857-8287
Mailing Address - Street 1:13837 MONTEREY LN
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-6592
Mailing Address - Country:US
Mailing Address - Phone:562-857-8287
Mailing Address - Fax:562-245-6539
Practice Address - Street 1:13837 MONTEREY LN
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-6592
Practice Address - Country:US
Practice Address - Phone:562-857-8287
Practice Address - Fax:562-245-6539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT20033BMedicare PIN