Basic Information
| Provider Information | |||||||||
| NPI: | 1407824170 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RANCHO PHYSICAL THERAPY, INC. | ||||||||
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| OtherOrganizationName: | RANCHO PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 27450 YNEZ RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925914671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516955144 | ||||||||
| FaxNumber: | 9516959345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 03/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | LITT | ||||||||
| AuthorizedOfficialFirstName: | GABRIELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 9516969353 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1407824170 | 05 | CA | MEDICAID | ZZZ60302Z | 01 | CA | BLUE SHIELD PT | OTHER | ZZZ02134Z | 01 | CA | BLUE SHIELD OT | OTHER |