Provider Demographics
NPI:1750537585
Name:PACK PHYSICAL THERAPY
Entity type:Organization
Organization Name:PACK PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRODIE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-443-0713
Mailing Address - Street 1:PO BOX 3255
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-8255
Mailing Address - Country:US
Mailing Address - Phone:949-443-0713
Mailing Address - Fax:
Practice Address - Street 1:24582 DEL PRADO STE E
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-3820
Practice Address - Country:US
Practice Address - Phone:949-443-0713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28869261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT28869Medicare PIN