Healthcare Provider Details

I. General information

NPI: 1851844708
Provider Name (Legal Business Name): REPAIR SPORTS INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S ANAHEIM BLVD SUITE 160
ANAHEIM CA
92805-6242
US

IV. Provider business mailing address

16561 BOLSA CHICA ST #107
HUNTINGTON BEACH CA
92649-3594
US

V. Phone/Fax

Practice location:
  • Phone: 714-377-4314
  • Fax:
Mailing address:
  • Phone: 714-377-4314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHAD S BEAUCHAMP
Title or Position: OWNER
Credential: PT, DPT, SCS,CSCS
Phone: 951-699-0303