Basic Information
| Provider Information | |||||||||
| NPI: | 1063465441 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALIFORNIA REHAB AND SPORTS THERAPY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CALIFORNIA HAND THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NEWPORT CENTER DR | ||||||||
| Address2: | #213 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926607501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496441322 | ||||||||
| FaxNumber: | 9496440316 | ||||||||
| Practice Location | |||||||||
| Address1: | 471 W LAMBERT RD | ||||||||
| Address2: | #106 | ||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928213921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142558877 | ||||||||
| FaxNumber: | 7142558878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | PACE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2138041712 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 20582 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ65266Z | 01 | CA | BLUE SHIELD | OTHER |