Healthcare Provider Details

I. General information

NPI: 1679906242
Provider Name (Legal Business Name): WATER'S EDGE PHYSICAL THERAPY AND WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2013
Last Update Date: 08/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 N COAST HIGHWAY 101 STE 120 1230 N COAST HIGHWAY 101 SUITE 130
ENCINITAS CA
92024-1493
US

IV. Provider business mailing address

2033 SAN ELIJO AVE 111
CARDIFF CA
92007-1726
US

V. Phone/Fax

Practice location:
  • Phone: 760-479-9801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number35208
License Number StateCA

VIII. Authorized Official

Name: SHANE CARPENTER
Title or Position: PRESIDENT/ PT, DPT
Credential: DPT
Phone: 831-419-8856