Provider Demographics
NPI:1518258532
Name:PRISTINE REHABCARE, INC
Entity Type:Organization
Organization Name:PRISTINE REHABCARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAYANTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:IYENGAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-396-8900
Mailing Address - Street 1:706 N DIAMOND BAR BLVD
Mailing Address - Street 2:SUITE B2
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1059
Mailing Address - Country:US
Mailing Address - Phone:909-396-8900
Mailing Address - Fax:909-861-3423
Practice Address - Street 1:706 N DIAMOND BAR BLVD
Practice Address - Street 2:SUITE B2
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1059
Practice Address - Country:US
Practice Address - Phone:909-396-8900
Practice Address - Fax:909-861-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1A19491252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency