Basic Information
| Provider Information | |||||||||
| NPI: | 1932728367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCE OCCUPATIONAL & HAND THERAPY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 ODYSSEY STE 165 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926183194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497272192 | ||||||||
| FaxNumber: | 9497272193 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 N BROOKHURST ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928015614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497272192 | ||||||||
| FaxNumber: | 9497272193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2020 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | REZAEI | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9497272192 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OTR/L, HTC | ||||||||
| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225XH1200X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 1093746752 | 05 | CA | MEDICAID |