Healthcare Provider Details

I. General information

NPI: 1477579977
Provider Name (Legal Business Name): CG PHYSICAL THERAPY SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12139 MOUNT VERNON AVE STE 110
GRAND TERRACE CA
92313-5500
US

IV. Provider business mailing address

PO BOX 3115
HAYDEN ID
83835-3115
US

V. Phone/Fax

Practice location:
  • Phone: 909-370-3396
  • Fax:
Mailing address:
  • Phone: 208-772-8147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT12588
License Number StateCA

VIII. Authorized Official

Name: GARY SCHNEIDER
Title or Position: PRESIDENT
Credential: P.T.
Phone: 208-772-8147