MEDICARE: RANCHO PHYSICAL THERAPY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist
2	225100000X	Physical Therapist		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ60304Z	OTHER	CA	BLUE SHIELD - PT
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	ZZZ05533Z	OTHER	CA	BLUE SHIELD - OT

General Provider Information

NPI Number	:	1407824162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANCHO PHYSICAL THERAPY, INC.

Provider Business Mailing Address
First Line	:	600 CENTRAL AVE STE C
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-2740
Country	:	US
Telephone Number	:	951-696-9353
Fax Number	:	951-973-7216

Provider Business Practice Location Address
First Line	:	31764 CASINO DR STE 106A&B
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-2312
Country	:	US
Telephone Number	:	951-471-3300
Fax Number	:	951-471-3301

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	GABRIELA LITT
Credential	:
Telephone Number	:	951-696-9353

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	03/14/2022

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