Provider Demographics
NPI:1114243904
Name:WAKABAYASHI PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:WAKABAYASHI PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKABAYASHI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:858-414-6552
Mailing Address - Street 1:4105 OCEAN VIEW BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1520
Mailing Address - Country:US
Mailing Address - Phone:818-792-5143
Mailing Address - Fax:
Practice Address - Street 1:4105 OCEAN VIEW BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020-1520
Practice Address - Country:US
Practice Address - Phone:818-792-5143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-19
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADI534AMedicare PIN