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?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty