Basic Information
| Provider Information | |||||||||
| NPI: | 1598711566 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PLAYA PHYSICAL THERAPY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PLAYA PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 13163 FOUNTAIN PARK DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PLAYA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900942040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108232220 | ||||||||
| FaxNumber: | 3108232636 | ||||||||
| Practice Location | |||||||||
| Address1: | 13163 FOUNTAIN PARK DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PLAYA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900942040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108232220 | ||||||||
| FaxNumber: | 3108232636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 09/06/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIS | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 3108232220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | ZZZ08931Z | 01 | CA | BLUE SHIELD PROVIDER # | OTHER |