=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457659583
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UP & MOVIN' PEDIATRIC PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2011
-----------------------------------------------------
Last Update Date | 03/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6180 BROCKTON AVE SUITE 202
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92506-2228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-961-9152
-----------------------------------------------------
Fax | 951-776-8028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17835 LUNA CT
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92504-9523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-961-9152
-----------------------------------------------------
Fax | 951-776-8028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY/TREASURER
-----------------------------------------------------
Name | MRS. JANE LOREI SPICKELMIER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 951-961-9152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | PJ3678C
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------