Provider Demographics
NPI:1578815999
Name:RANCHO PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:RANCHO PHYSICAL THERAPY, INC.
Other - Org Name:RANCHO PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-696-9353
Mailing Address - Street 1:600 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:277 RANCHEROS DR
Practice Address - Street 2:STE. 150
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2976
Practice Address - Country:US
Practice Address - Phone:760-752-1011
Practice Address - Fax:760-752-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1578815999Medicaid
CAZZZ71426YOtherBLUE SHIELD OF CALIFORNIA