=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306814124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | XCELERATE PHYSICAL THERAPY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2006
-----------------------------------------------------
Last Update Date | 08/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3180 WILLOW LN STE 104
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91361-4979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-374-9900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3262 E THOUSAND OAKS BLVD STE 100
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91362-3443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PT
-----------------------------------------------------
Name | BRANDON DEDERICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 805-552-1915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------