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General NPI Number Information
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NPI Number | 1366484131
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Entity Type | Organization
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Legal Business Name | WIMBLEDON PARK PHYSICAL THERAPY
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Dates
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Enumeration Date | 06/13/2006
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Last Update Date | 08/13/2007
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Provider Practice Location Address
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Address Line | 12611 HESPERIA RD STE B
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City | VICTORVILLE
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State | CA
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Zip | 92395-7720
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Country | US
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Telephone | 760-951-9702
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Fax | 760-951-8594
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Provider Business Mailing Address
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Address Line | 12611 HESPERIA RD STE B
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City | VICTORVILLE
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State | CA
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Zip | 92395-7720
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Country | US
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Telephone | 760-951-9702
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Fax | 760-951-8594
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Authorized Official
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Title or Position | MANAGER
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Name | MR. JERRY HOPPER
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Credential | PT
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Telephone | 760-951-9702
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT13643
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License Number State | CA
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