Healthcare Provider Details

I. General information

NPI: 1912836511
Provider Name (Legal Business Name): REALFORM PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 W LAS TUNAS DR STE 205
SAN GABRIEL CA
91776-1266
US

IV. Provider business mailing address

317 W LAS TUNAS DR STE 205
SAN GABRIEL CA
91776-1266
US

V. Phone/Fax

Practice location:
  • Phone: 415-932-9046
  • Fax:
Mailing address:
  • Phone: 415-932-9046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ANTHONY LIN LIANG
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 415-932-9046