Provider Demographics
NPI:1952518714
Name:CONTRA COSTA PHYSICAL THERAPY
Entity Type:Organization
Organization Name:CONTRA COSTA PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:CYRIL
Authorized Official - Last Name:MALIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:510-758-1111
Mailing Address - Street 1:3065 RICHMOND PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-5718
Mailing Address - Country:US
Mailing Address - Phone:510-758-1111
Mailing Address - Fax:
Practice Address - Street 1:3065 RICHMOND PKWY STE 105
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-5718
Practice Address - Country:US
Practice Address - Phone:510-758-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11158261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT11158OtherPHYSICAL THERAPY LICENSE