Provider Demographics
NPI:1902438898
Name:INTENT PERFORMANCE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:INTENT PERFORMANCE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:JEFFRIES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:949-433-8160
Mailing Address - Street 1:118 E AVENIDA SAN JUAN
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3231
Mailing Address - Country:US
Mailing Address - Phone:949-433-8160
Mailing Address - Fax:
Practice Address - Street 1:118 E AVENIDA SAN JUAN
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3231
Practice Address - Country:US
Practice Address - Phone:949-433-8160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy