Basic Information
| Provider Information | |||||||||
| NPI: | 1508018789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CASA COLINA COMPREHENSIVE OUTPATIENT REHABILITATION SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 E BONITA AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917671923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094500105 | ||||||||
| FaxNumber: | 9095930153 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 E BONITA AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917671923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095967733 | ||||||||
| FaxNumber: | 9095930153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 08/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | LOVERSO | ||||||||
| AuthorizedOfficialFirstName: | FELICE | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9095967733 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CASA COLINA SLEEP CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
No ID Information.