Healthcare Provider Details

I. General information

NPI: 1114198462
Provider Name (Legal Business Name): MERCEDES ENTERPRISE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 W DUARTE RD SUITE 1
ARCADIA CA
91007-7618
US

IV. Provider business mailing address

660 W DUARTE RD SUITE 1
ARCADIA CA
91007-7618
US

V. Phone/Fax

Practice location:
  • Phone: 626-445-1978
  • Fax: 626-574-1999
Mailing address:
  • Phone: 626-445-1978
  • Fax: 626-574-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT5821
License Number StateCA

VIII. Authorized Official

Name: JOE SAM BORLAND
Title or Position: PHYSICAL THERAPIST
Credential: D.O., R.P.T.
Phone: 626-445-1978