Provider Demographics
NPI:1922773159
Name:BRIDGE PHYSICAL THERAPY PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BRIDGE PHYSICAL THERAPY PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEDENT
Authorized Official - Prefix:
Authorized Official - First Name:SE JIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:213-268-7218
Mailing Address - Street 1:6301 BEACH BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2840
Mailing Address - Country:US
Mailing Address - Phone:657-255-4252
Mailing Address - Fax:657-255-4258
Practice Address - Street 1:6301 BEACH BLVD STE 102
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2840
Practice Address - Country:US
Practice Address - Phone:657-255-4252
Practice Address - Fax:657-255-4258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty