Healthcare Provider Details

I. General information

NPI: 1104023464
Provider Name (Legal Business Name): ULTIMATE PHYSICAL THERAPY AND REHABILITATION CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 SAN GABRIEL BLVD SUITE 104
ROSEMEAD CA
91770-5204
US

IV. Provider business mailing address

2630 SAN GABRIEL BLVD SUITE 104
ROSEMEAD CA
91770-5204
US

V. Phone/Fax

Practice location:
  • Phone: 626-307-1718
  • Fax:
Mailing address:
  • Phone: 626-307-1718
  • 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 Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: NIEVES BERNARDINO DACLISON
Title or Position: PRESIDENT
Credential: PT
Phone: 626-307-1718