Provider Demographics
NPI:1730260407
Name:JORDAN PHYSICAL THERAPY CENTER INC
Entity type:Organization
Organization Name:JORDAN PHYSICAL THERAPY CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:760-568-2894
Mailing Address - Street 1:42080 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-5173
Mailing Address - Country:US
Mailing Address - Phone:760-568-2894
Mailing Address - Fax:760-346-4179
Practice Address - Street 1:42080 STATE STREET
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-5173
Practice Address - Country:US
Practice Address - Phone:760-568-2894
Practice Address - Fax:760-568-2894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE9702OtherPALMETTO GBA
693682OtherACN
CAZZZ64862ZOtherBLUE SHIELD OF CA
CAZZZ64862ZOtherBLUE SHIELD OF CA
CAZZZ31730ZMedicare PIN