Provider Demographics
NPI:1003798182
Name:JORDAN RIVER PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:JORDAN RIVER PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FUAD
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-DABBAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-528-8288
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-0386
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34247 YUCAIPA BLVD STE E
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-6118
Practice Address - Country:US
Practice Address - Phone:909-657-2232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-22
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA680529Medicaid
CACA687754Medicaid