Provider Demographics
NPI:1689754194
Name:PHYSICAL THERAPY CENTER, INC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY CENTER, INC
Other - Org Name:A.C.I.C. PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENJI
Authorized Official - Middle Name:
Authorized Official - Last Name:YOSHINO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, AT, C
Authorized Official - Phone:949-754-1344
Mailing Address - Street 1:16253 LAGUNA CANYON RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3605
Mailing Address - Country:US
Mailing Address - Phone:949-754-1344
Mailing Address - Fax:949-754-1351
Practice Address - Street 1:16253 LAGUNA CANYON RD
Practice Address - Street 2:SUITE 140
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3605
Practice Address - Country:US
Practice Address - Phone:949-754-1344
Practice Address - Fax:949-754-1351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT7583225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14763Medicare PIN