Healthcare Provider Details

I. General information

NPI: 1295782894
Provider Name (Legal Business Name): DARWIN LANCE FOGT MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11825 MAJOR ST
CULVER CITY CA
90230-6356
US

IV. Provider business mailing address

322 CULVER BLVD
PLAYA DEL REY CA
90293-7784
US

V. Phone/Fax

Practice location:
  • Phone: 310-915-6100
  • Fax: 310-915-0100
Mailing address:
  • Phone: 310-915-6100
  • Fax: 310-915-0100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT26595
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: