Provider Demographics
NPI:1366449118
Name:FORGERON PHYSICAL THERAPY
Entity type:Organization
Organization Name:FORGERON PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORGERON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:760-778-7150
Mailing Address - Street 1:555 E TACHEVAH DR
Mailing Address - Street 2:1 EAST #201
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-5750
Mailing Address - Country:US
Mailing Address - Phone:760-778-7150
Mailing Address - Fax:760-778-7180
Practice Address - Street 1:555 E TACHEVAH DR
Practice Address - Street 2:1 EAST #201
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5750
Practice Address - Country:US
Practice Address - Phone:760-778-7150
Practice Address - Fax:760-778-7180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10849225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABS296ZOtherPTAN
CAAV430YOtherPTAN
CADF558ZOtherPTAN
CA35396OtherPHYSICAL THERAPY BOARD OF CALIFORNIA
CAPT26534OtherPHYSICAL THERAPY LICENSE
CAPT35038OtherPHYSICAL THERAPY BOARD OF CALIFORNIA
CA0PT303570Medicare PIN
CA0PT225970Medicare PIN
CAPT35038OtherPHYSICAL THERAPY BOARD OF CALIFORNIA
CADF558ZOtherPTAN
CA0PT227811Medicare PIN
CABS296ZOtherPTAN
CAAV430YOtherPTAN