Healthcare Provider Details

I. General information

NPI: 1386821619
Provider Name (Legal Business Name): KIDS ON THE GO PHYSICAL THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7629 GIRARD AVE STE 201
LA JOLLA CA
92037-0076
US

IV. Provider business mailing address

7629 GIRARD AVE STE 201
LA JOLLA CA
92037-0076
US

V. Phone/Fax

Practice location:
  • Phone: 773-495-6522
  • Fax: 858-255-8364
Mailing address:
  • Phone: 773-495-6522
  • Fax: 858-255-8364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24707
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number24707
License Number StateCA

VIII. Authorized Official

Name: MS. MARY HERMES
Title or Position: PHYSICAL THERAPIST/ OWNER
Credential: P.T.
Phone: 773-495-6522