Provider Demographics
NPI:1952511461
Name:XCEL ORTHOPAEDIC PHYSICAL THERAPY
Entity Type:Organization
Organization Name:XCEL ORTHOPAEDIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEVRA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BOMMARITO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:209-599-7073
Mailing Address - Street 1:103 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-2416
Mailing Address - Country:US
Mailing Address - Phone:209-599-7073
Mailing Address - Fax:209-599-7074
Practice Address - Street 1:103 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-2416
Practice Address - Country:US
Practice Address - Phone:209-599-7073
Practice Address - Fax:209-599-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CA15780225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18198ZMedicare UPIN