Provider Demographics
NPI:1073633384
Name:EASTBLUFF PHYSICAL REHABILITATION, INC.
Entity Type:Organization
Organization Name:EASTBLUFF PHYSICAL REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:LUCCHESI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-760-9545
Mailing Address - Street 1:301 VISTA SUERTE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-3516
Mailing Address - Country:US
Mailing Address - Phone:949-760-9545
Mailing Address - Fax:
Practice Address - Street 1:2600 EAST PACIFIC COAST HIGHWAY
Practice Address - Street 2:SUITE 240
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625
Practice Address - Country:US
Practice Address - Phone:949-760-9545
Practice Address - Fax:714-968-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2251E1200X, 2251H1200X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomicsGroup - Single Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADP177AMedicare PIN
R37065Medicare UPIN