Provider Demographics
NPI:1316974181
Name:TRI-CITIES PHYSICAL THERAPY
Entity type:Organization
Organization Name:TRI-CITIES PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:ROYAL
Authorized Official - Last Name:METHVIN
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:760-946-2165
Mailing Address - Street 1:19031 OUTER HIGHWAY 18
Mailing Address - Street 2:STE 100
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307
Mailing Address - Country:US
Mailing Address - Phone:760-946-2165
Mailing Address - Fax:760-946-2169
Practice Address - Street 1:19031 US HIGHWAY 18
Practice Address - Street 2:STE 100
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2515
Practice Address - Country:US
Practice Address - Phone:760-946-2165
Practice Address - Fax:760-946-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty