Healthcare Provider Details

I. General information

NPI: 1821680174
Provider Name (Legal Business Name): M.A.S. PERFORMANCEPHYSIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 WHITNEY DR
ALHAMBRA CA
91803-4429
US

IV. Provider business mailing address

2640 WHITNEY DR
ALHAMBRA CA
91803-4429
US

V. Phone/Fax

Practice location:
  • Phone: 626-260-5015
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY SU
Title or Position: PRESIDENT
Credential:
Phone: 626-260-5015