Provider Demographics
NPI:1972010908
Name:MATTHEW P DANNEKER
Entity Type:Organization
Organization Name:MATTHEW P DANNEKER
Other - Org Name:KINESIO PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:P
Authorized Official - Last Name:DANNEKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-503-5455
Mailing Address - Street 1:738 W CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-7230
Mailing Address - Country:US
Mailing Address - Phone:760-503-5455
Mailing Address - Fax:
Practice Address - Street 1:16049 TUSCOLA RD STE A
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-0824
Practice Address - Country:US
Practice Address - Phone:909-263-2094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-29
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251X0800X
CA33987261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty