Provider Demographics
NPI:1932948585
Name:EXPERIENCE PHYSICAL THERAPY CORP.
Entity type:Organization
Organization Name:EXPERIENCE PHYSICAL THERAPY CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:510-371-1178
Mailing Address - Street 1:4793 PHEBE AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-2502
Mailing Address - Country:US
Mailing Address - Phone:510-371-1178
Mailing Address - Fax:
Practice Address - Street 1:1860 MOWRY AVE STE 102
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1730
Practice Address - Country:US
Practice Address - Phone:510-371-1178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty