Provider Demographics
NPI:1417242454
Name:RANCHO PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:RANCHO PHYSICAL THERAPY, INC.
Other - Org Name:OPTIMISSPORT PT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-696-9353
Mailing Address - Street 1:600 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:910 VIA DE LA PAZ STE 101
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3538
Practice Address - Country:US
Practice Address - Phone:310-573-9340
Practice Address - Fax:310-573-9328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-17
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ68108YOtherBLUE SHIELD OF CALIFORNIA
CAW14904Medicare PIN