Healthcare Provider Details

I. General information

NPI: 1649737982
Provider Name (Legal Business Name): LA ORTHOPEDIC AND PEDIATRIC PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16055 VENTURA BLVD STE 825
ENCINO CA
91436-2617
US

IV. Provider business mailing address

16055 VENTURA BLVD STE 825
ENCINO CA
91436-2617
US

V. Phone/Fax

Practice location:
  • Phone: 323-680-5616
  • Fax: 323-935-5933
Mailing address:
  • Phone: 323-680-5616
  • Fax: 323-935-5933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA MAZALIAN
Title or Position: CFO/OWNER
Credential: DPT, OCS
Phone: 818-747-4189