Provider Demographics
NPI:1104002518
Name:WELLCARE PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:WELLCARE PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:JIMENEZ
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:323-982-1566
Mailing Address - Street 1:4157 EAGLE ROCK BLVD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-4492
Mailing Address - Country:US
Mailing Address - Phone:323-982-1566
Mailing Address - Fax:323-982-1680
Practice Address - Street 1:4157 EAGLE ROCK BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90065-4492
Practice Address - Country:US
Practice Address - Phone:323-982-1566
Practice Address - Fax:323-982-1680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15084225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty