Provider Demographics
NPI:1598919268
Name:MEDSTAR PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:MEDSTAR PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALFONSO
Authorized Official - Last Name:HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:ETC
Authorized Official - Phone:626-641-5125
Mailing Address - Street 1:275 W SAN BERNARDINO RD
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1516
Mailing Address - Country:US
Mailing Address - Phone:626-967-3553
Mailing Address - Fax:626-915-7403
Practice Address - Street 1:275 W SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1516
Practice Address - Country:US
Practice Address - Phone:626-967-3553
Practice Address - Fax:626-915-7403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty