Provider Demographics
NPI:1114417938
Name:WALNUT PHYSICAL THERAPY AND PERFORMANCE P.C.
Entity Type:Organization
Organization Name:WALNUT PHYSICAL THERAPY AND PERFORMANCE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILLY
Authorized Official - Middle Name:CHAN
Authorized Official - Last Name:KOH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:909-468-0438
Mailing Address - Street 1:138 PIERRE RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2531
Mailing Address - Country:US
Mailing Address - Phone:909-468-0438
Mailing Address - Fax:909-992-3303
Practice Address - Street 1:138 PIERRE RD
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2531
Practice Address - Country:US
Practice Address - Phone:909-468-0438
Practice Address - Fax:909-992-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT42770261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy