Provider Demographics
NPI:1477753861
Name:AEGIS PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:AEGIS PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMENECH
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:760-322-5090
Mailing Address - Street 1:27620 LANDAU BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-5540
Mailing Address - Country:US
Mailing Address - Phone:760-322-5090
Mailing Address - Fax:760-322-9175
Practice Address - Street 1:27620 LANDAU BLVD STE 3
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-5540
Practice Address - Country:US
Practice Address - Phone:760-322-5090
Practice Address - Fax:760-322-9175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64403ZOtherBLUE SHIELD GROUP
CAZZZ64403ZOtherBLUE SHIELD GROUP
CADE2363Medicare PIN