Basic Information
| Provider Information | |||||||||
| NPI: | 1255301461 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POMONA VALLEY ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GARY M. SOUZA, PT & ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21015 PATHFINDER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917654018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098613511 | ||||||||
| FaxNumber: | 9098607900 | ||||||||
| Practice Location | |||||||||
| Address1: | 21015 PATHFINDER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917654018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098613511 | ||||||||
| FaxNumber: | 9098607900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOUZA | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER,PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9098613511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPT, OCS | ||||||||
| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT10462 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | DC9491 | 01 | CA | RAILROAD MEDICARE GROUP # | OTHER |