Provider Demographics
NPI:1790771640
Name:CORONA PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:CORONA PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANADO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:951-737-1965
Mailing Address - Street 1:1113 S MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-4412
Mailing Address - Country:US
Mailing Address - Phone:951-737-1965
Mailing Address - Fax:
Practice Address - Street 1:1113 S MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-4412
Practice Address - Country:US
Practice Address - Phone:951-737-1965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22178ZMedicare ID - Type Unspecified