Provider Demographics
NPI:1316367915
Name:PREMIER HOME PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:PREMIER HOME PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BERKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-918-0765
Mailing Address - Street 1:3146 CROWNVIEW DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-6414
Mailing Address - Country:US
Mailing Address - Phone:310-918-0765
Mailing Address - Fax:
Practice Address - Street 1:1300 W 6TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3531
Practice Address - Country:US
Practice Address - Phone:310-519-1030
Practice Address - Fax:310-519-0194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26104261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT26104OtherMEDICARE PTAN