Basic Information
Provider Information | |||||||||
NPI: | 1285602946 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RANCHO PHYSICAL THERAPY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RANCHO PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 CENTRAL AVE STE C | ||||||||
Address2: |   | ||||||||
City: | LAKE ELSINORE | ||||||||
State: | CA | ||||||||
PostalCode: | 925302740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516969353 | ||||||||
FaxNumber: | 9519737216 | ||||||||
Practice Location | |||||||||
Address1: | 24021 ALESSANDRO BLVD STE 109 | ||||||||
Address2: |   | ||||||||
City: | MORENO VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 925536709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9514854594 | ||||||||
FaxNumber: | 9514859560 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2006 | ||||||||
LastUpdateDate: | 03/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LITT | ||||||||
AuthorizedOfficialFirstName: | GABRIELA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 9516969353 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | ZZZ05525Z | 01 | CA | BLUE SHIELD - OT | OTHER | ZZZ36686Z | 01 | CA | BLUE SHIELD - PT | OTHER | 1285602946 | 05 | CA |   | MEDICAID |