Basic Information
Provider Information | |||||||||
NPI: | 1669554325 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMPLETE CARE PHYSICAL THERAPY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4050 AIRPORT CENTER DR | ||||||||
Address2: | SUITE D | ||||||||
City: | PALM SPRINGS | ||||||||
State: | CA | ||||||||
PostalCode: | 922641216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7603255950 | ||||||||
FaxNumber: | 7603255945 | ||||||||
Practice Location | |||||||||
Address1: | 552 S PASEO DOROTEA STE 4 | ||||||||
Address2: |   | ||||||||
City: | PALM SPRINGS | ||||||||
State: | CA | ||||||||
PostalCode: | 922641437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7603255950 | ||||||||
FaxNumber: | 7603255945 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2006 | ||||||||
LastUpdateDate: | 11/26/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NELSON | ||||||||
AuthorizedOfficialFirstName: | JANETTE | ||||||||
AuthorizedOfficialMiddleName: | FAYE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7603255950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | P.T. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT8791 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.