Provider Demographics
NPI:1104023464
Name:ULTIMATE PHYSICAL THERAPY AND REHABILITATION CLINIC INC
Entity type:Organization
Organization Name:ULTIMATE PHYSICAL THERAPY AND REHABILITATION CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NIEVES
Authorized Official - Middle Name:BERNARDINO
Authorized Official - Last Name:DACLISON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:626-307-1718
Mailing Address - Street 1:2630 SAN GABRIEL BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-5204
Mailing Address - Country:US
Mailing Address - Phone:626-307-1718
Mailing Address - Fax:
Practice Address - Street 1:2630 SAN GABRIEL BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-5204
Practice Address - Country:US
Practice Address - Phone:626-307-1718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherEIN