Provider Demographics
NPI:1538192695
Name:ADVANCE THERAPY PHYSICAL THERAPY CLINIC, INC
Entity type:Organization
Organization Name:ADVANCE THERAPY PHYSICAL THERAPY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAHAKYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-240-5512
Mailing Address - Street 1:1415 E COLORADO ST STE 212
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 E COLORADO ST STE 212
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1541
Practice Address - Country:US
Practice Address - Phone:818-240-5512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18602Medicare ID - Type Unspecified