Provider Demographics
NPI:1164595633
Name:EUGENE A. SHALES PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:EUGENE A. SHALES PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHFET
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:310-474-8111
Mailing Address - Street 1:10817 SANTA MONICA BLVD
Mailing Address - Street 2:#300
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4655
Mailing Address - Country:US
Mailing Address - Phone:310-474-8111
Mailing Address - Fax:310-474-3237
Practice Address - Street 1:10817 SANTA MONICA BLVD
Practice Address - Street 2:#300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4655
Practice Address - Country:US
Practice Address - Phone:310-474-8111
Practice Address - Fax:310-474-3237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7354225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT7354Medicare ID - Type UnspecifiedJOHN MAHFET PT
CAWPT 1728Medicare ID - Type UnspecifiedSANDY PENDO PT
CAW16360Medicare ID - Type UnspecifiedGROUP ID NUMBER
CAWPT28854Medicare ID - Type UnspecifiedMITZI ELA PT