Provider Demographics
NPI:1689748329
Name:PLAZA VERDUGO FITNESS & REHABILITATION, PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PLAZA VERDUGO FITNESS & REHABILITATION, PHYSICAL THERAPY, INC.
Other - Org Name:PLAZA VERDUGO FITNESS & REHAB, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MEAD
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:818-952-8707
Mailing Address - Street 1:1809 VERDUGO BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1809 VERDUGO BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1402
Practice Address - Country:US
Practice Address - Phone:818-952-8707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 56973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17101Medicare PIN