Provider Demographics
NPI:1811441629
Name:ON TRACK PHYSICAL THERAPY AND PERFORMANCE, P.C.
Entity type:Organization
Organization Name:ON TRACK PHYSICAL THERAPY AND PERFORMANCE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:PHILLIPS
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-917-9886
Mailing Address - Street 1:309 GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-3219
Mailing Address - Country:US
Mailing Address - Phone:831-917-9886
Mailing Address - Fax:
Practice Address - Street 1:220 COUNTRY CLUB GATE CTR
Practice Address - Street 2:#11
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950-5014
Practice Address - Country:US
Practice Address - Phone:831-917-9886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty