Provider Demographics
NPI:1114981925
Name:ORTHO THERAPEUTICS
Entity Type:Organization
Organization Name:ORTHO THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTER PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MANIJEH
Authorized Official - Middle Name:
Authorized Official - Last Name:EZATVAR
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:805-375-0001
Mailing Address - Street 1:PO BOX 6874
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91359-6874
Mailing Address - Country:US
Mailing Address - Phone:805-375-0001
Mailing Address - Fax:805-375-2221
Practice Address - Street 1:1000 NEWBURY RD
Practice Address - Street 2:SUITE # 120
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-3613
Practice Address - Country:US
Practice Address - Phone:805-375-0001
Practice Address - Fax:805-375-2221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W18109Medicare PIN
Q27316Medicare UPIN
WPT19200AMedicare PIN