Healthcare Provider Details

I. General information

NPI: 1952244204
Provider Name (Legal Business Name): OLD TOWN PHYSICAL THERAPY CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 TIGER LILY LN
IMPERIAL CA
92251-8930
US

IV. Provider business mailing address

600 TIGER LILY LN
IMPERIAL CA
92251-8930
US

V. Phone/Fax

Practice location:
  • Phone: 619-818-8609
  • Fax:
Mailing address:
  • Phone: 619-818-8609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: EMILIANO E CHAVEZ
Title or Position: PRESIDENT
Credential: CCC-SLP
Phone: 619-818-8609