Provider Demographics
NPI:1811008964
Name:INNISS/NEILSON PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:INNISS/NEILSON PHYSICAL THERAPY, INC.
Other - Org Name:BONITA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NEILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:619-422-3970
Mailing Address - Street 1:264 LANDIS AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2651
Mailing Address - Country:US
Mailing Address - Phone:619-422-3970
Mailing Address - Fax:
Practice Address - Street 1:264 LANDIS AVE STE 103
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2651
Practice Address - Country:US
Practice Address - Phone:619-422-3970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 16623225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14508Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER