Provider Demographics
NPI:1932398450
Name:SHYAM ULLAL,PT A PROF.CORP
Entity Type:Organization
Organization Name:SHYAM ULLAL,PT A PROF.CORP
Other - Org Name:FRONTIER WORKER FITNESS & THERAPY SEVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHYAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:ULLAL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:760-357-8864
Mailing Address - Street 1:2330 SANDALWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-3674
Mailing Address - Country:US
Mailing Address - Phone:760-357-8864
Mailing Address - Fax:760-357-8866
Practice Address - Street 1:408 E 3RD ST
Practice Address - Street 2:SUITE F
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-2854
Practice Address - Country:US
Practice Address - Phone:760-357-8864
Practice Address - Fax:760-357-8866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 10423261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT10423AOtherINDIVDUAL PTAN
CAW14493Medicare PIN