Provider Demographics
NPI:1689905325
Name:RANCHO PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:RANCHO PHYSICAL THERAPY, INC.
Other - Org Name:RANCHO PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-696-9353
Mailing Address - Street 1:600 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:11276 5TH ST STE 400
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0923
Practice Address - Country:US
Practice Address - Phone:909-481-0437
Practice Address - Fax:909-481-0837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2022-03-14
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
CAZZZ60929ZOtherBLUE SHIELD OF CALIFORNIA
CA1689905325Medicaid