Provider Demographics
NPI:1962601146
Name:PHYSICAL THERAPY CENTER OF TUSTIN, INC
Entity type:Organization
Organization Name:PHYSICAL THERAPY CENTER OF TUSTIN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:EIRICH
Authorized Official - Suffix:
Authorized Official - Credentials:PT14722
Authorized Official - Phone:714-505-2966
Mailing Address - Street 1:18102 IRVINE BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3424
Mailing Address - Country:US
Mailing Address - Phone:714-505-2966
Mailing Address - Fax:714-505-2976
Practice Address - Street 1:18102 IRVINE BLVD STE 207
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3424
Practice Address - Country:US
Practice Address - Phone:714-505-2966
Practice Address - Fax:714-505-2976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14722225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19679Medicare PIN