Provider Demographics
NPI:1043342397
Name:CUSTOM P.T., A PHYSICAL THERAPY CORP
Entity type:Organization
Organization Name:CUSTOM P.T., A PHYSICAL THERAPY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAOLONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-446-3141
Mailing Address - Street 1:325 ROLLING OAKS DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1088
Mailing Address - Country:US
Mailing Address - Phone:805-446-3141
Mailing Address - Fax:805-446-3140
Practice Address - Street 1:22122 SHERMAN WAY
Practice Address - Street 2:SUITE 106
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1140
Practice Address - Country:US
Practice Address - Phone:818-592-6030
Practice Address - Fax:818-592-6034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2014-11-07
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
CAW19073Medicare ID - Type UnspecifiedMEDICARE ID
CAW19073Medicare PIN