Provider Demographics
NPI:1609117829
Name:MKC PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:MKC PHYSICAL THERAPY, INC
Other - Org Name:ADVANCED PHYSIOTHERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CAZALAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-573-6373
Mailing Address - Street 1:PO BOX 2736
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91979-2736
Mailing Address - Country:US
Mailing Address - Phone:619-573-6373
Mailing Address - Fax:
Practice Address - Street 1:860 JAMACHA RD
Practice Address - Street 2:SUITE 203
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-6206
Practice Address - Country:US
Practice Address - Phone:619-573-6373
Practice Address - Fax:619-378-6578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-13
Last Update Date:2014-02-20
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
CACB207118Medicare PIN