Provider Demographics
NPI:1366771602
Name:GLEASON PHYSICAL THERAPY INC.
Entity type:Organization
Organization Name:GLEASON PHYSICAL THERAPY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:949-542-5000
Mailing Address - Street 1:31461 RANCHO VIEJO RD
Mailing Address - Street 2:STE 101
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1864
Mailing Address - Country:US
Mailing Address - Phone:949-542-5000
Mailing Address - Fax:949-419-2650
Practice Address - Street 1:31461 RANCHO VIEJO RD
Practice Address - Street 2:STE 101
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1864
Practice Address - Country:US
Practice Address - Phone:949-542-5000
Practice Address - Fax:949-419-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT29291BMedicare PIN