Provider Demographics
NPI:1053490557
Name:CANYON LAKE PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:CANYON LAKE PHYSICAL THERAPY, INC
Other - Org Name:CANYON LAKE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:STACY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MOMT
Authorized Official - Phone:951-246-2670
Mailing Address - Street 1:31700 RAILROAD CANYON RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-9453
Mailing Address - Country:US
Mailing Address - Phone:951-246-2670
Mailing Address - Fax:951-246-2672
Practice Address - Street 1:31700 RAILROAD CANYON RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CANYON LAKE
Practice Address - State:CA
Practice Address - Zip Code:92587-9453
Practice Address - Country:US
Practice Address - Phone:951-246-2670
Practice Address - Fax:951-246-2672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 9115225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT91150Medicare ID - Type UnspecifiedPROVIDER NUMBER