Provider Demographics
NPI:1376726349
Name:INTERSTATE REHAB
Entity Type:Organization
Organization Name:INTERSTATE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PIETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-244-5656
Mailing Address - Street 1:333 E GLENOAKS BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207-2074
Mailing Address - Country:US
Mailing Address - Phone:818-244-5656
Mailing Address - Fax:
Practice Address - Street 1:3055 W ORANGE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3159
Practice Address - Country:US
Practice Address - Phone:818-244-5656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty