Provider Demographics
NPI:1215071485
Name:OPTIMUM PHYSICAL THERAPY & WELLNESS
Entity type:Organization
Organization Name:OPTIMUM PHYSICAL THERAPY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-790-9010
Mailing Address - Street 1:PO BOX 11955
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-1955
Mailing Address - Country:US
Mailing Address - Phone:909-797-9010
Mailing Address - Fax:909-797-9046
Practice Address - Street 1:34213 YUCAIPA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2494
Practice Address - Country:US
Practice Address - Phone:909-797-9010
Practice Address - Fax:909-797-9046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26164ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER