Healthcare Provider Details

I. General information

NPI: 1376602268
Provider Name (Legal Business Name): C O R E PHYSICAL THERAPY OF VISALIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 N CHINOWTH ST
VISALIA CA
93291
US

IV. Provider business mailing address

1138 N CHINOWTH ST
VISALIA CA
93291-4113
US

V. Phone/Fax

Practice location:
  • Phone: 559-713-1222
  • Fax: 559-713-1234
Mailing address:
  • Phone: 559-713-1222
  • Fax: 559-713-1234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22909
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT22909
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberSP9406
License Number StateCA

VIII. Authorized Official

Name: MR. BRYAN R PACILLAS
Title or Position: CEO
Credential: MPT
Phone: 559-679-2797