Basic Information
| Provider Information | |||||||||
| NPI: | 1184898215 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROSTAR SPORTS TRAINING AND REHABILITATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1370 VALLEY VISTA DR STE 145 | ||||||||
| Address2: | |||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917653950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098613511 | ||||||||
| FaxNumber: | 9098607900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1370 VALLEY VISTA DR STE 145 | ||||||||
| Address2: | |||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917653950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098613511 | ||||||||
| FaxNumber: | 9098607900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2008 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | SOUZA | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9098613511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10462 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.