Provider Demographics
NPI:1518119130
Name:ADVANTAGE REHAB & ORTHOPEDIC PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:ADVANTAGE REHAB & ORTHOPEDIC PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:909-396-0309
Mailing Address - Street 1:1249 S. DIAMOND BAR BLVD.
Mailing Address - Street 2:# 112
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4122
Mailing Address - Country:US
Mailing Address - Phone:909-396-0309
Mailing Address - Fax:909-396-0619
Practice Address - Street 1:1200 S. DIAMOND BAR BLVD.
Practice Address - Street 2:# 108
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4122
Practice Address - Country:US
Practice Address - Phone:909-396-0309
Practice Address - Fax:909-396-0619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABQ091AMedicare PIN