MEDICARE: SOUTH PACIFIC REHABILITATION SERVICES, INC

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	261QH0700X	Hearing and Speech Clinic/Center	SP14161	CA

General Provider Information

NPI Number	:	1811348857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH PACIFIC REHABILITATION SERVICES, INC

Provider Business Mailing Address
First Line	:	12047 STEWARTON DR
Second Line	:
City	:	PORTER RANCH
State	:	CA
Zip	:	91326-1156
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12047 STEWARTON DR
Second Line	:
City	:	PORTER RANCH
State	:	CA
Zip	:	91326-1156
Country	:	US
Telephone Number	:	818-216-0008
Fax Number	:

Authorized Official
Title or Position	:	SPEECH-LANGUAGE PATHOLOGIST
Name	:	KATHERINE DE LOS TRINOS DUQUE
Credential	:	M.S. CCC-SLP
Telephone Number	:	818-216-0008

Provider Enumeration Date	:	06/30/2016
Last Update Date	:	06/30/2016

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