Provider Demographics
NPI:1356383913
Name:LB PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:LB PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PT
Authorized Official - Prefix:MR
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:NATION
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:209-826-8623
Mailing Address - Street 1:820 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4124
Mailing Address - Country:US
Mailing Address - Phone:209-826-8623
Mailing Address - Fax:209-826-1433
Practice Address - Street 1:820 2ND ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4124
Practice Address - Country:US
Practice Address - Phone:209-826-8623
Practice Address - Fax:209-826-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ26987ZMedicare ID - Type Unspecified