1104917095 NPI number — MARY LYDIA ENGLES

Table of content: (NPI 1104917095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104917095 NPI number — MARY LYDIA ENGLES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY LYDIA ENGLES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SPORTS ARENA PHYSICAL THERAPY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104917095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4120 WEST POINT LOMA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92110-5605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-226-4131
Provider Business Mailing Address Fax Number:
619-226-4124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4120 WEST POINT LOMA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-5605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-226-4131
Provider Business Practice Location Address Fax Number:
619-226-4124
Provider Enumeration Date:
09/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ENGLES
Authorized Official First Name:
MARY
Authorized Official Middle Name:
LYDIA
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
619-226-4131

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  PT6252 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)