MEDICARE: SPORT CENTRAL OSTEOPATHIC, A MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	G72600	CA
2	208100000X	Physical Medicine & Rehabilitation Physician	G72600	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G726000	OTHER	CA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1144557729
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORT CENTRAL OSTEOPATHIC, A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	14069 MARQUESAS WAY
Second Line	:	SUITE 216D
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-6052
Country	:	US
Telephone Number	:	310-301-3031
Fax Number	:	310-301-3001

Provider Business Practice Location Address
First Line	:	8879 LAUREL CANYON BLVD
Second Line	:	SUITE C
City	:	SUN VALLEY
State	:	CA
Zip	:	91352-2959
Country	:	US
Telephone Number	:	818-252-2000
Fax Number	:	818-252-6896

Authorized Official
Title or Position	:	DIRECTOR
Name	:	PAUL M ROBINSON
Credential	:	MD
Telephone Number	:	818-955-5112

Provider Enumeration Date	:	11/03/2009
Last Update Date	:	03/27/2010

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