Provider Demographics
NPI:1851754428
Name:CARRICO PEDIATRIC THERAPY, INC.
Entity Type:Organization
Organization Name:CARRICO PEDIATRIC THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRICO
Authorized Official - Suffix:
Authorized Official - Credentials:MA, OTR/L
Authorized Official - Phone:562-607-1937
Mailing Address - Street 1:1301 W ARROW HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2330
Mailing Address - Country:US
Mailing Address - Phone:909-599-8084
Mailing Address - Fax:909-929-0805
Practice Address - Street 1:1301 W ARROW HWY
Practice Address - Street 2:SUITE 130
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2330
Practice Address - Country:US
Practice Address - Phone:909-599-8084
Practice Address - Fax:909-929-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11906252Y00000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No252Y00000XAgenciesEarly Intervention Provider Agency