Provider Demographics
NPI:1588614788
Name:PACIFIC REHAB, INC.
Entity Type:Organization
Organization Name:PACIFIC REHAB, INC.
Other - Org Name:ADVANCE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:PAZ
Authorized Official - Last Name:MAMARIL
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:909-835-0638
Mailing Address - Street 1:PO BOX 12112
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-2112
Mailing Address - Country:US
Mailing Address - Phone:909-835-0638
Mailing Address - Fax:760-416-9852
Practice Address - Street 1:101 E REDLANDS BLVD
Practice Address - Street 2:SUITE 245
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4775
Practice Address - Country:US
Practice Address - Phone:909-835-0638
Practice Address - Fax:760-416-9852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 29464261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy