=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104023464
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ULTIMATE PHYSICAL THERAPY AND REHABILITATION CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2630 SAN GABRIEL BLVD SUITE 104
-----------------------------------------------------
City | ROSEMEAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91770-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-307-1718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2630 SAN GABRIEL BLVD SUITE 104
-----------------------------------------------------
City | ROSEMEAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91770-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-307-1718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NIEVES BERNARDINO DACLISON
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 626-307-1718
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------