Basic Information
| Provider Information | |||||||||
| NPI: | 1740708429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONSTITUTION ROAD HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JULIA TEMPLE OUTPATIENT SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27101 PUERTA REAL STE 450 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926918566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495401249 | ||||||||
| FaxNumber: | 9495401966 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 S LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037610075 | ||||||||
| FaxNumber: | 3037612967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2017 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | BURNAM | ||||||||
| AuthorizedOfficialFirstName: | SOON | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9495401249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
No ID Information.