Provider Demographics
NPI:1255446860
Name:CARLSON PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:CARLSON PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:949-713-7939
Mailing Address - Street 1:8 YELLOWPINE LN
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-1420
Mailing Address - Country:US
Mailing Address - Phone:949-713-7939
Mailing Address - Fax:
Practice Address - Street 1:8 YELLOWPINE LN
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679-1420
Practice Address - Country:US
Practice Address - Phone:949-713-7939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190332251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16499Medicare ID - Type Unspecified