Healthcare Provider Details

I. General information

NPI: 1205766714
Provider Name (Legal Business Name): KINETICS PHYSICAL THERAPY PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 W 5TH ST
SAN DIMAS CA
91773-2014
US

IV. Provider business mailing address

406 W 5TH ST
SAN DIMAS CA
91773-2014
US

V. Phone/Fax

Practice location:
  • Phone: 909-288-2670
  • Fax: 520-372-2043
Mailing address:
  • Phone: 909-288-2670
  • Fax: 520-372-2043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251H1300X
TaxonomyHuman Factors Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MELINDA PELOQUIN
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 949-215-5008