Provider Demographics
NPI:1093046286
Name:PRISTINE REHAB CARE
Entity Type:Organization
Organization Name:PRISTINE REHAB CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KISHORE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANTAMANENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-396-8900
Mailing Address - Street 1:706 N DIAMOND BAR BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1059
Mailing Address - Country:US
Mailing Address - Phone:909-396-8900
Mailing Address - Fax:909-396-9900
Practice Address - Street 1:706 N DIAMOND BAR BLVD STE B
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1059
Practice Address - Country:US
Practice Address - Phone:909-396-8900
Practice Address - Fax:909-396-9900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency