Provider Demographics
NPI:1649691932
Name:MB PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:MB PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:SKALAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:949-330-3832
Mailing Address - Street 1:32061 CAMINO DEL CIELO
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-3440
Mailing Address - Country:US
Mailing Address - Phone:949-330-3832
Mailing Address - Fax:
Practice Address - Street 1:2010 WILSHIRE BLVD STE 809
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3594
Practice Address - Country:US
Practice Address - Phone:213-252-1985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty