Provider Demographics
NPI:1457332884
Name:MOJAVE VALLEY PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MOJAVE VALLEY PHYSICAL THERAPY
Other - Org Name:KAREN K. KITELEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:KITELEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:760-245-3769
Mailing Address - Street 1:15095 AMARGOSA RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-1879
Mailing Address - Country:US
Mailing Address - Phone:760-245-3769
Mailing Address - Fax:760-245-5145
Practice Address - Street 1:15095 AMARGOSA RD
Practice Address - Street 2:SUITE 104
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-1879
Practice Address - Country:US
Practice Address - Phone:760-245-3769
Practice Address - Fax:760-245-5145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT7048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT70480Medicare PIN