Healthcare Provider Details

I. General information

NPI: 1154689925
Provider Name (Legal Business Name): LAWRENCE S LEVY P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11479 JEFFERSON BLVD
CULVER CITY CA
90232
US

IV. Provider business mailing address

11479 JEFFERSON BLVD
CULVER CITY CA
90232
US

V. Phone/Fax

Practice location:
  • Phone: 310-313-3939
  • Fax: 310-326-7222
Mailing address:
  • Phone: 310-313-3939
  • Fax: 310-326-7222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT#12989
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: