Provider Demographics
NPI:1982642336
Name:MAGNOLIA PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:MAGNOLIA PHYSICAL THERAPY, INC
Other - Org Name:ANAHEIM PHYSICAL THERAPY AND AQUATIC REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FRACALOSY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:714-968-3003
Mailing Address - Street 1:19032 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-2232
Mailing Address - Country:US
Mailing Address - Phone:714-968-3003
Mailing Address - Fax:714-968-4220
Practice Address - Street 1:19032 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-2232
Practice Address - Country:US
Practice Address - Phone:714-968-3003
Practice Address - Fax:714-968-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA165984261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16005AMedicare ID - Type UnspecifiedMEDICARE PROVIDER # NHIC