Provider Demographics
NPI:1386899763
Name:DIVINE HEALTH PROVIDER PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:DIVINE HEALTH PROVIDER PHYSICAL THERAPY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONAH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, PA-C
Authorized Official - Phone:805-581-4266
Mailing Address - Street 1:1687 ERRINGER RD STE 109
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6509
Mailing Address - Country:US
Mailing Address - Phone:805-581-4266
Mailing Address - Fax:805-581-5049
Practice Address - Street 1:1687 ERRINGER RD STE 109
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-6509
Practice Address - Country:US
Practice Address - Phone:805-581-4266
Practice Address - Fax:805-581-5049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24912261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ07077Medicare UPIN