1346619210 NPI number — PROSPORT PHYSICAL THERAPY PROFESSIONALS INC

Table of Contents

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:
Provider Other Organization Name Type Code:
6
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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