Provider Demographics
NPI:1629182720
Name:CORE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:CORE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:NISHIJIMA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:408-379-3021
Mailing Address - Street 1:1 W CAMPBELL AVE
Mailing Address - Street 2:SUITE D36
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1004
Mailing Address - Country:US
Mailing Address - Phone:408-379-3021
Mailing Address - Fax:408-379-3024
Practice Address - Street 1:1 W CAMPBELL AVE
Practice Address - Street 2:SUITE D36
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1004
Practice Address - Country:US
Practice Address - Phone:408-379-3021
Practice Address - Fax:408-379-3024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2013-05-14
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
CAZZZ02004ZMedicare ID - Type Unspecified