Provider Demographics
NPI:1609258128
Name:JADE PHYSICAL THERAPY & WELLNESS INC
Entity Type:Organization
Organization Name:JADE PHYSICAL THERAPY & WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:SOUTULLO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:626-566-8332
Mailing Address - Street 1:819 WRIGHT AVE
Mailing Address - Street 2:APT 28
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-4474
Mailing Address - Country:US
Mailing Address - Phone:786-306-0778
Mailing Address - Fax:888-624-7542
Practice Address - Street 1:1575 N LAKE AVE
Practice Address - Street 2:STE 205
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2340
Practice Address - Country:US
Practice Address - Phone:626-566-8332
Practice Address - Fax:888-624-7542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-20
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41255261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy