Provider Demographics
NPI:1376602268
Name:C O R E PHYSICAL THERAPY OF VISALIA INC
Entity Type:Organization
Organization Name:C O R E PHYSICAL THERAPY OF VISALIA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PACILLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:559-679-2797
Mailing Address - Street 1:1138 N CHINOWTH ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4113
Mailing Address - Country:US
Mailing Address - Phone:559-713-1222
Mailing Address - Fax:559-713-1234
Practice Address - Street 1:1138 N CHINOWTH ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291
Practice Address - Country:US
Practice Address - Phone:559-713-1222
Practice Address - Fax:559-713-1234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22909225100000X, 2251X0800X
CASP9406231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64366ZOtherBLUE SHIELD
CAZZZ32795ZMedicare ID - Type UnspecifiedOUT PATIENT PHYSICAL THER