Provider Demographics
NPI:1083846976
Name:PRIMITIVE THERAPY PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:PRIMITIVE THERAPY PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:949-310-4276
Mailing Address - Street 1:22691 LAMBERT ST #520
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1614
Mailing Address - Country:US
Mailing Address - Phone:949-310-4276
Mailing Address - Fax:888-390-1433
Practice Address - Street 1:22691 LAMBERT ST STE 520
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1614
Practice Address - Country:US
Practice Address - Phone:949-310-4276
Practice Address - Fax:888-390-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACL344AOtherMEDICARE PTAN