Provider Demographics
NPI:1336250992
Name:IMPERIAL BURBANK PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:IMPERIAL BURBANK PHYSICAL THERAPY INC
Other - Org Name:IMPERIAL PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:KUSKIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:8918-846-1441
Mailing Address - Street 1:2222 W BURBANK BLVD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1280
Mailing Address - Country:US
Mailing Address - Phone:818-846-1441
Mailing Address - Fax:818-846-1419
Practice Address - Street 1:2222 W BURBANK BLVD UNIT 101
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1280
Practice Address - Country:US
Practice Address - Phone:818-846-1441
Practice Address - Fax:818-846-1419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18923Medicare ID - Type Unspecified
CA=========OtherPHYSICAL THERAPY