Basic Information
| Provider Information | |||||||||
| NPI: | 1093746752 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCE OCCUPATIONAL & HAND THERAPY CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SEVEN TO 7 PHYSICAL & HAND THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 ODYSSEY | ||||||||
| Address2: | SUITE #: 165 | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926183186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497272192 | ||||||||
| FaxNumber: | 9497272193 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 ODYSSEY STE 165 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926183194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492853098 | ||||||||
| FaxNumber: | 9497272193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REZAEI | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9497272192 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OTR/L, HTC | ||||||||
| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT38428 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT33635 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225XH1200X | OT1251 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 3791439 | 05 | CA | MEDICAID | OT0012510 | 01 | CA | BLUE SHIELD | OTHER | ZZZ64792Z | 01 | CA | BLUE SHIELD | OTHER |