1346619210 NPI number — PROSPORT PHYSICAL THERAPY PROFESSIONALS INC

Table of content: (NPI 1346619210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346619210 NPI number — PROSPORT PHYSICAL THERAPY PROFESSIONALS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROSPORT PHYSICAL THERAPY PROFESSIONALS 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:
PROSPORT PHYSICAL THERAPY-LAGUNA HILLS, INC
Provider Other Organization Name Type Code:
4
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:
1346619210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14155
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92863-1555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-450-4999
Provider Business Mailing Address Fax Number:
714-974-0055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23001 DEL LAGO DR
Provider Second Line Business Practice Location Address:
SUITE C-1
Provider Business Practice Location Address City Name:
LAGUNA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92653-1354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-387-7333
Provider Business Practice Location Address Fax Number:
949-916-7309
Provider Enumeration Date:
09/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ISMAIL
Authorized Official First Name:
BOBBY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
209-353-1988

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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