Provider Demographics
NPI:1225485436
Name:HEREL PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:HEREL PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:HEREL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:607-761-4992
Mailing Address - Street 1:11911 SAN VICENTE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5086
Mailing Address - Country:US
Mailing Address - Phone:607-761-4992
Mailing Address - Fax:
Practice Address - Street 1:11427 CULVER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6009
Practice Address - Country:US
Practice Address - Phone:607-761-4992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42569261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy