Provider Demographics
NPI:1720023658
Name:ADVANCED PERFORMANCE PHYSICAL THERAPY AND REHABILITATION, INC
Entity Type:Organization
Organization Name:ADVANCED PERFORMANCE PHYSICAL THERAPY AND REHABILITATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:W
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:805-735-8365
Mailing Address - Street 1:1201 E. OCEAN AVENUE, STE. A
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436
Mailing Address - Country:US
Mailing Address - Phone:805-735-8365
Mailing Address - Fax:805-735-2604
Practice Address - Street 1:1201 E. OCEAN AVENUE, STE. A
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436
Practice Address - Country:US
Practice Address - Phone:805-735-8365
Practice Address - Fax:805-735-2604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26087225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5965750001Medicare NSC