Provider Demographics
NPI: | 1295383941 |
---|---|
Name: | DEVELOPMENTAL PHYSICAL THERAPY |
Entity Type: | Organization |
Organization Name: | DEVELOPMENTAL PHYSICAL THERAPY |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MPT/OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KIMBERLY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | CLARK |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PT |
Authorized Official - Phone: | 714-624-2315 |
Mailing Address - Street 1: | 101 S KRAEMER BLVD STE 125 |
Mailing Address - Street 2: | |
Mailing Address - City: | PLACENTIA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92870-6100 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 714-624-2315 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 101 S KRAEMER BLVD STE 125 |
Practice Address - Street 2: | |
Practice Address - City: | PLACENTIA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92870-6100 |
Practice Address - Country: | US |
Practice Address - Phone: | 714-624-2315 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-08-27 |
Last Update Date: | 2019-08-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Single Specialty |