Provider Demographics
NPI:1134237985
Name:SAN CLEMENTE PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:SAN CLEMENTE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER PT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:REENDERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:949-240-0600
Mailing Address - Street 1:647 CAMINO DE LOS MARES
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2806
Mailing Address - Country:US
Mailing Address - Phone:949-240-0600
Mailing Address - Fax:949-240-7578
Practice Address - Street 1:647 CAMINO DE LOS MARES
Practice Address - Street 2:SUITE 111
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2806
Practice Address - Country:US
Practice Address - Phone:949-240-0600
Practice Address - Fax:949-240-7578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 7668225100000X
CAAT 2864225200000X
CAPT 9681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17972Medicare PIN