Provider Demographics
NPI:1912953936
Name:FAIRBANKS & POWER PHYSICAL THERAPY CORP.
Entity Type:Organization
Organization Name:FAIRBANKS & POWER PHYSICAL THERAPY CORP.
Other - Org Name:PACIFICPRO PHYSICAL THERAPY & SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:SNYDER
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:949-679-3988
Mailing Address - Street 1:2 PETERS CANYON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1798
Mailing Address - Country:US
Mailing Address - Phone:949-679-3988
Mailing Address - Fax:949-679-7665
Practice Address - Street 1:2 PETERS CANYON RD STE 100
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-1798
Practice Address - Country:US
Practice Address - Phone:949-679-3988
Practice Address - Fax:949-679-7665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24608225100000X
CA24357225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ08309ZOtherBLUE SHIELD OF CA PIN
CAZZZ08309ZOtherBLUE SHIELD OF CA PIN
CAW17135Medicare ID - Type UnspecifiedGROUP ID