1285135301 NPI number — COMPLEX REHAB SPECIALIST

Table of content: (NPI 1285135301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285135301 NPI number — COMPLEX REHAB SPECIALIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPLEX REHAB SPECIALIST
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:
1285135301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1215 W IMPERIAL HWY STE 101B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92821-3738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-597-0609
Provider Business Mailing Address Fax Number:
866-597-0609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 IMPERIAL HWY STE 470
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92835-1063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-597-0609
Provider Business Practice Location Address Fax Number:
866-597-0609
Provider Enumeration Date:
02/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HAUSER
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
GARY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
866-597-0609

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  ATP1528 , 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)

  • Identifier: SRRC103216572 . This is a "RESALE CERTIFICATE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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