Basic Information
| Provider Information | |||||||||
| NPI: | 1669948337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SGH REHAB INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 872 | ||||||||
| Address2: | |||||||||
| City: | AGOURA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913760872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185187226 | ||||||||
| FaxNumber: | 8186712225 | ||||||||
| Practice Location | |||||||||
| Address1: | 38600 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935514483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098448960 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2018 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | HUMPHRIES | ||||||||
| AuthorizedOfficialFirstName: | STEFAN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5098448960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | C158938 | 01 | CA | MEDICAL LICENSE | OTHER |