Healthcare Provider Details

I. General information

NPI: 1851754428
Provider Name (Legal Business Name): CARRICO PEDIATRIC THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W ARROW HWY SUITE 130
SAN DIMAS CA
91773-2330
US

IV. Provider business mailing address

1301 W ARROW HWY SUITE 130
SAN DIMAS CA
91773-2330
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-8084
  • Fax: 909-929-0805
Mailing address:
  • Phone: 909-599-8084
  • Fax: 909-929-0805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number11906
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number11906
License Number StateCA

VIII. Authorized Official

Name: LAN CARRICO
Title or Position: OCCUPATIONAL THERAPIST
Credential: M.A., OTR/L
Phone: 562-607-1937