Organization
PRIMITIVE THERAPY PHYSICAL THERAPY INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JACOB MATTHEW CALDWELL DPT (OWNER)
(949) 310-4276
Entity
Organization
Contact information
Practice address
22691 LAMBERT ST STE 520, LAKE FOREST, CA 92630-1614
(949) 310-4276
(888) 390-1433
Mailing address
22691 LAMBERT ST #520, LAKE FOREST, CA 92630-1614
(949) 310-4276
(888) 390-1433
Taxonomy
Speciality
Code
Description
License number
State
261QP2000X
Physical Therapy Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CL344A
MEDICARE PTAN
CA
Enumeration date
08/11/2009
Last updated
12/07/2009
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