=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114034576
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WCPT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1265 AVOCADO AVE 104-197
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020-7783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-368-4855
-----------------------------------------------------
Fax | 619-390-8312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 374 H ST STE 102
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-5547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-691-0345
-----------------------------------------------------
Fax | 619-691-0131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KEITH D BRADY
-----------------------------------------------------
Credential | MBA CHE
-----------------------------------------------------
Telephone | 619-368-4855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------