Provider Demographics
NPI:1366484131
Name:WIMBLEDON PARK PHYSICAL THERAPY
Entity Type:Organization
Organization Name:WIMBLEDON PARK PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOPPER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:760-951-9702
Mailing Address - Street 1:12611 HESPERIA RD
Mailing Address - Street 2:STE B
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7720
Mailing Address - Country:US
Mailing Address - Phone:760-951-9702
Mailing Address - Fax:760-951-8594
Practice Address - Street 1:12611 HESPERIA RD
Practice Address - Street 2:STE B
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7720
Practice Address - Country:US
Practice Address - Phone:760-951-9702
Practice Address - Fax:760-951-8594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13643225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PT129400Medicare PIN