=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235224593
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODY CENTER PHYSICAL THERAPY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 03/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 N INDIAN HILL BLVD
-----------------------------------------------------
City | CLAREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91711-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-621-0447
-----------------------------------------------------
Fax | 626-821-5434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224 N INDIAN HILL BLVD
-----------------------------------------------------
City | CLAREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91711-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-621-0447
-----------------------------------------------------
Fax | 626-821-5434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFFREY LAURENCE FAIRLEY
-----------------------------------------------------
Credential | PT, DPT, OCS
-----------------------------------------------------
Telephone | 626-664-2827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT25533
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | PT 25533
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT 25533
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------