=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114417938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALNUT PHYSICAL THERAPY AND PERFORMANCE P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2018
-----------------------------------------------------
Last Update Date | 05/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 138 PIERRE RD
-----------------------------------------------------
City | WALNUT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91789-2531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-468-0438
-----------------------------------------------------
Fax | 909-992-3303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 138 PIERRE RD
-----------------------------------------------------
City | WALNUT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91789-2531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-468-0438
-----------------------------------------------------
Fax | 909-992-3303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LILLY CHAN KOH
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 909-468-0438
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT42770
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------