Provider Demographics
NPI:1598820862
Name:PACIFIC THERAPY AND REHAB, INC
Entity Type:Organization
Organization Name:PACIFIC THERAPY AND REHAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-832-9656
Mailing Address - Street 1:PO BOX 610638
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95161-0638
Mailing Address - Country:US
Mailing Address - Phone:408-832-9656
Mailing Address - Fax:
Practice Address - Street 1:696 E SANTA CLARA ST
Practice Address - Street 2:SUITE 209
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-1911
Practice Address - Country:US
Practice Address - Phone:408-993-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT5979225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5638760002Medicare NSC
CAZZZ20467ZMedicare UPIN