Provider Demographics
NPI:1639107626
Name:CUSTOM P.T., A PHYSICAL THERAPY CORP
Entity Type:Organization
Organization Name:CUSTOM P.T., A PHYSICAL THERAPY CORP
Other - Org Name:CUSTOM PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAOLONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-446-3141
Mailing Address - Street 1:325 ROLLING OAKS DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1088
Mailing Address - Country:US
Mailing Address - Phone:805-446-3141
Mailing Address - Fax:805-446-3140
Practice Address - Street 1:325 ROLLING OAKS DRIVE
Practice Address - Street 2:SUITE 210
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1088
Practice Address - Country:US
Practice Address - Phone:805-446-3141
Practice Address - Fax:805-446-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT200942251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19073Medicare PIN
CAW19073Medicare PIN