Basic Information
| Provider Information | |||||||||
| NPI: | 1538445119 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH PACIFIC REHAB SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16260 VENTURA BLVD | ||||||||
| Address2: | 600 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189861977 | ||||||||
| FaxNumber: | 8189864757 | ||||||||
| Practice Location | |||||||||
| Address1: | 4940 VAN NUYS BLVD | ||||||||
| Address2: | 301 | ||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189905050 | ||||||||
| FaxNumber: | 8189909449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2011 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | COHEN | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8189861977 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.