Provider Demographics
NPI:1255301461
Name:POMONA VALLEY ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:POMONA VALLEY ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, OCS
Authorized Official - Phone:909-861-3511
Mailing Address - Street 1:21015 PATHFINDER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4018
Mailing Address - Country:US
Mailing Address - Phone:909-861-3511
Mailing Address - Fax:909-860-7900
Practice Address - Street 1:21015 PATHFINDER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4018
Practice Address - Country:US
Practice Address - Phone:909-861-3511
Practice Address - Fax:909-860-7900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10462225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC9491OtherRAILROAD MEDICARE GROUP #
CAZZZ14471ZOtherBLUE SHIELD PROV #
CAW15030Medicare ID - Type UnspecifiedMEDICARE GROUP PROV #