1194950667 NPI number — PHYSICAL THERAPY AND SPORTS MEDICINE CENTER

Table of content: (NPI 1316059892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194950667 NPI number — PHYSICAL THERAPY AND SPORTS MEDICINE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL THERAPY AND SPORTS MEDICINE CENTER
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:
1194950667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5565 GROSSMONT CENTER DRIVE
Provider Second Line Business Mailing Address:
BLDG. 3 SUITE 461
Provider Business Mailing Address City Name:
LA MESA
Provider Business Mailing Address State Name:
CALIFORNIA
Provider Business Mailing Address Postal Code:
91942
Provider Business Mailing Address Country Code:
UM
Provider Business Mailing Address Telephone Number:
619-589-0850
Provider Business Mailing Address Fax Number:
619-589-0878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5565 GROSSMONT CENTER DR
Provider Second Line Business Practice Location Address:
BLDG. 3, SUITE 461
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-3020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-589-0850
Provider Business Practice Location Address Fax Number:
619-589-0878
Provider Enumeration Date:
05/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBSON
Authorized Official First Name:
BETH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
619-589-0850

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  PT8986 , 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)





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