Healthcare Provider Details

I. General information

NPI: 1982930392
Provider Name (Legal Business Name): NATURAL HEALTH SPORTS THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1784 NEWPORT BLVD
COSTA MESA CA
92627-2756
US

IV. Provider business mailing address

1784 NEWPORT BLVD
COSTA MESA CA
92627-2756
US

V. Phone/Fax

Practice location:
  • Phone: 949-645-4086
  • Fax: 949-645-2014
Mailing address:
  • Phone: 949-645-4086
  • Fax: 949-645-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MARK ROCHE
Title or Position: PTA
Credential: PTA
Phone: 949-645-4086