Basic Information
| Provider Information | |||||||||
| NPI: | 1417242454 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RANCHO PHYSICAL THERAPY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPTIMISSPORT PT | ||||||||
| 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: | 910 VIA DE LA PAZ STE 101 | ||||||||
| Address2: | |||||||||
| City: | PACIFIC PALISADES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902723538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105739340 | ||||||||
| FaxNumber: | 3105739328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2011 | ||||||||
| LastUpdateDate: | 03/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | LITT | ||||||||
| AuthorizedOfficialFirstName: | GABRIELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9516969353 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| 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 | ZZZ68108Y | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER |