Provider Demographics
NPI:1629193305
Name:XCEL ORTHOPAEDIC PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:XCEL ORTHOPAEDIC PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEVRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOMMARITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-546-0944
Mailing Address - Street 1:1429 W FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-2627
Mailing Address - Country:US
Mailing Address - Phone:209-546-0944
Mailing Address - Fax:
Practice Address - Street 1:1429 W FREMONT ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2627
Practice Address - Country:US
Practice Address - Phone:209-546-0944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15780261QH0100X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ51476ZOtherBLUE SHIELD PROVIDER NUMB
CAZZZ18198ZMedicare PIN