Provider Demographics
NPI:1275085235
Name:123 PEDIATRIC THERAPY, A PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:123 PEDIATRIC THERAPY, A PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:APRIL
Authorized Official - Last Name:HWANG
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:909-964-2186
Mailing Address - Street 1:926 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-2835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:855 N LARK ELLEN AVE
Practice Address - Street 2:SUITE L
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-1099
Practice Address - Country:US
Practice Address - Phone:909-964-2186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy