Provider Demographics
NPI:1295904308
Name:PARK MEDICAL PHYSICAL THERAPY, PROF CORP
Entity type:Organization
Organization Name:PARK MEDICAL PHYSICAL THERAPY, PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:619-297-2544
Mailing Address - Street 1:4136 BACHMAN PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2028
Mailing Address - Country:US
Mailing Address - Phone:619-297-2544
Mailing Address - Fax:619-297-2752
Practice Address - Street 1:4120 W POINT LOMA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5605
Practice Address - Country:US
Practice Address - Phone:619-297-2544
Practice Address - Fax:619-297-2752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT7388332BC3200X, 332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR37322Medicare UPIN