1063521987 NPI number — TECH COAST REHAB INC

Table of content: (NPI 1063521987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063521987 NPI number — TECH COAST REHAB INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TECH COAST REHAB INC
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:
Provider Other Organization Name Type Code:
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:
1063521987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4200 TRABUCO RD
Provider Second Line Business Mailing Address:
SUITE 165
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92620-3600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-654-1369
Provider Business Mailing Address Fax Number:
949-654-1383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 TRABUCO RD
Provider Second Line Business Practice Location Address:
SUITE 165
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92620-3600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-654-1369
Provider Business Practice Location Address Fax Number:
949-654-1383
Provider Enumeration Date:
08/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GAITA
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
CECILE
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
949-654-1369

Provider Taxonomy Codes

  • Taxonomy code: 225000000X , with the licence number:  2033 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225XE1200X , with the licence number: 2033 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225XH1200X , with the licence number: 2033 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225XN1300X , with the licence number: 2033 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 5797733 . This is a "AETNA PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: OT0020330 . This is a "BLUE SHIELD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ05623Z . This is a "BLUE SHIELD GROUP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".