Healthcare Provider Details

I. General information

NPI: 1689752834
Provider Name (Legal Business Name): MILPITAS PHYSICAL THERAPY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 S PARK VICTORIA DR
MILPITAS CA
95035-6942
US

IV. Provider business mailing address

1103 S PARK VICTORIA DR
MILPITAS CA
95035-6942
US

V. Phone/Fax

Practice location:
  • Phone: 408-263-2020
  • Fax: 408-263-8537
Mailing address:
  • Phone: 408-263-2020
  • Fax: 408-263-8537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number09361
License Number StateCA

VIII. Authorized Official

Name: DAVID SEVERSON
Title or Position: OWNER/DIRECTOR
Credential: P.T.
Phone: 408-263-2020