Provider Demographics
NPI:1972526358
Name:EDIZON PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:EDIZON PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:HENDRICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:GANDING
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:760-246-8846
Mailing Address - Street 1:11336 BARTLETT AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:ADELANTO
Mailing Address - State:CA
Mailing Address - Zip Code:92301-1950
Mailing Address - Country:US
Mailing Address - Phone:760-246-8846
Mailing Address - Fax:760-246-3118
Practice Address - Street 1:11336 BARTLETT AVE STE 11
Practice Address - Street 2:
Practice Address - City:ADELANTO
Practice Address - State:CA
Practice Address - Zip Code:92301-1950
Practice Address - Country:US
Practice Address - Phone:760-246-8846
Practice Address - Fax:760-246-3118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03083ZMedicare PIN