Provider Demographics
NPI:1407824162
Name:RANCHO PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:RANCHO PHYSICAL THERAPY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-696-9353
Mailing Address - Street 1:600 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:31764 CASINO DR STE 106A&B
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-2312
Practice Address - Country:US
Practice Address - Phone:951-471-3300
Practice Address - Fax:951-471-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
225X00000X
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
CAZZZ60304ZOtherBLUE SHIELD - PT
CA1407824162Medicaid
CAZZZ05533ZOtherBLUE SHIELD - OT