Basic Information
| Provider Information | |||||||||
| NPI: | 1649779919 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREEN PHYSICAL THERAPY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREEN PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23100 EUCALYPTUS AVE STE C | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925535439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513791500 | ||||||||
| FaxNumber: | 9513791501 | ||||||||
| Practice Location | |||||||||
| Address1: | 23100 EUCALYPTUS AVE STE C | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925535439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513791500 | ||||||||
| FaxNumber: | 9513791501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2018 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | GLYNISS | ||||||||
| AuthorizedOfficialMiddleName: | CLAUDETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 9513791500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, DPT, OCS | ||||||||
| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 22650 | CA | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 22650 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.