Healthcare Provider Details

I. General information

NPI: 1174095863
Provider Name (Legal Business Name): 360 WELLNESS PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S VINCENT AVE
WEST COVINA CA
91790-6712
US

IV. Provider business mailing address

11 ROCK SPRINGS WAY
AZUSA CA
91702-6270
US

V. Phone/Fax

Practice location:
  • Phone: 909-570-7787
  • Fax:
Mailing address:
  • Phone: 909-570-7787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251C2600X
TaxonomyCardiopulmonary Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: YURONG LU
Title or Position: PRESIDENT/PHYSICAL THERAPIST
Credential:
Phone: 909-570-7787