Provider Demographics
NPI:1578531398
Name:ATHLETIC & INDUSTRIAL REHABILITATN PHYSICAL THERAPY INC A PROF CORP
Entity Type:Organization
Organization Name:ATHLETIC & INDUSTRIAL REHABILITATN PHYSICAL THERAPY INC A PROF CORP
Other - Org Name:AIR PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRES OF CORP
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLAUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:209-529-1709
Mailing Address - Street 1:450 GLASS LN STE C
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9287
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:2116 E ORANGEBURG AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3370
Practice Address - Country:US
Practice Address - Phone:209-529-1709
Practice Address - Fax:209-572-2841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT8536261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ03193ZMedicare ID - Type Unspecified