Basic Information
| Provider Information | |||||||||
| NPI: | 1740847425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRETZ | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 S SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902666814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105463461 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 S SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902666814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105463461 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2019 | ||||||||
| LastUpdateDate: | 05/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 296692 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.