Provider Demographics
NPI:1508933052
Name:AGAPE PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:AGAPE PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ATALLA
Authorized Official - Last Name:SHAHID
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:626-857-4711
Mailing Address - Street 1:1347 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-5046
Mailing Address - Country:US
Mailing Address - Phone:626-857-4711
Mailing Address - Fax:626-857-4712
Practice Address - Street 1:1347 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5046
Practice Address - Country:US
Practice Address - Phone:626-857-4711
Practice Address - Fax:626-857-4712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20032225100000X
CAPT19905225100000X
CAOT260225XH1200X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16122Medicare ID - Type UnspecifiedINDEP PRACTICE PHYS THERA