Provider Demographics
NPI:1922140003
Name:INDIVIDUALIZED PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:INDIVIDUALIZED PHYSICAL THERAPY, INC
Other - Org Name:INDIVIDUALIZED PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:HALMOS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, ATC, CSCS
Authorized Official - Phone:408-778-6800
Mailing Address - Street 1:17705 HALE AVE STE H6
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-4340
Mailing Address - Country:US
Mailing Address - Phone:408-778-6800
Mailing Address - Fax:408-762-4488
Practice Address - Street 1:17705 HALE AVE STE H6
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-4340
Practice Address - Country:US
Practice Address - Phone:408-778-6800
Practice Address - Fax:408-762-4488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64853ZOtherBLUE SHIELD OF CA
CAZZZ64853ZOtherBLUE SHIELD OF CA