Provider Demographics
NPI:1497230759
Name:WAVE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:WAVE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NAVDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:LOOMBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-552-4230
Mailing Address - Street 1:15632 BEAR VALLEY RD STE 108
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8518
Mailing Address - Country:US
Mailing Address - Phone:760-552-4230
Mailing Address - Fax:760-245-8855
Practice Address - Street 1:15632 BEAR VALLEY RD STE 108
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8518
Practice Address - Country:US
Practice Address - Phone:760-552-4230
Practice Address - Fax:760-245-8855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9717838Medicaid