Provider Demographics
NPI:1962568493
Name:PACIFIC THERAPY AND REHAB, INC
Entity type:Organization
Organization Name:PACIFIC THERAPY AND REHAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-832-9656
Mailing Address - Street 1:PO BOX 610638
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95161-0638
Mailing Address - Country:US
Mailing Address - Phone:408-832-9656
Mailing Address - Fax:510-505-9880
Practice Address - Street 1:39159 PASEO PADRE PKWY
Practice Address - Street 2:SUITE 111
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1608
Practice Address - Country:US
Practice Address - Phone:510-505-9800
Practice Address - Fax:510-505-9880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT5979261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03837ZMedicare UPIN
CA5638760001Medicare NSC
CAZZZ03880ZMedicare ID - Type UnspecifiedPPIN