Healthcare Provider Details

I. General information

NPI: 1609258128
Provider Name (Legal Business Name): JADE PHYSICAL THERAPY & WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2015
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 N LAKE AVE STE 205
PASADENA CA
91104-2340
US

IV. Provider business mailing address

819 WRIGHT AVE APT 28
PASADENA CA
91104-4474
US

V. Phone/Fax

Practice location:
  • Phone: 626-566-8332
  • Fax: 888-624-7542
Mailing address:
  • Phone: 786-306-0778
  • Fax: 888-624-7542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number41255
License Number StateCA

VIII. Authorized Official

Name: FERNANDO LUIS SOUTULLO
Title or Position: PRESIDENT
Credential: PT
Phone: 626-566-8332