Provider Demographics
NPI:1710934666
Name:ANAHEIM PHYSICAL THERAPY AND AQUATIC REHAB
Entity Type:Organization
Organization Name:ANAHEIM PHYSICAL THERAPY AND AQUATIC REHAB
Other - Org Name:MAGNOLIA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FRACALOSY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:714-808-0008
Mailing Address - Street 1:1189 N EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1938
Mailing Address - Country:US
Mailing Address - Phone:714-808-0008
Mailing Address - Fax:714-808-0168
Practice Address - Street 1:1189 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1938
Practice Address - Country:US
Practice Address - Phone:714-808-0008
Practice Address - Fax:714-808-0168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABUS2003-01454261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPT001610Medicaid
CAGPT001610Medicaid