Provider Demographics
NPI:1790839710
Name:LA MESA PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:LA MESA PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:NASH
Authorized Official - Suffix:
Authorized Official - Credentials:MED, RPT
Authorized Official - Phone:619-464-1352
Mailing Address - Street 1:8939 LA MESA BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-9057
Mailing Address - Country:US
Mailing Address - Phone:619-464-1352
Mailing Address - Fax:619-464-7255
Practice Address - Street 1:8939 LA MESA BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-9057
Practice Address - Country:US
Practice Address - Phone:619-464-1352
Practice Address - Fax:619-464-7255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15063Medicare PIN