Provider Demographics
NPI:1073702965
Name:PERSONAL CARE PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:PERSONAL CARE PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:FAVIS
Authorized Official - Last Name:SAMONTE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:562-522-1111
Mailing Address - Street 1:357 AQUA WAY
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-2161
Mailing Address - Country:US
Mailing Address - Phone:562-522-1111
Mailing Address - Fax:
Practice Address - Street 1:357 AQUA WAY
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821
Practice Address - Country:US
Practice Address - Phone:562-522-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT27960OtherMEDICARE PROVIDER