Provider Demographics
NPI:1427075050
Name:MIRAGE PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:MIRAGE PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:MCNEILL
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:760-328-3950
Mailing Address - Street 1:35900 BOB HOPE DR
Mailing Address - Street 2:SUITE# 225
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1766
Mailing Address - Country:US
Mailing Address - Phone:760-328-3950
Mailing Address - Fax:760-328-3951
Practice Address - Street 1:35900 BOB HOPE DR
Practice Address - Street 2:SUITE# 225
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1766
Practice Address - Country:US
Practice Address - Phone:760-328-3950
Practice Address - Fax:760-328-3951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23575174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty