Healthcare Provider Details

I. General information

NPI: 1902848492
Provider Name (Legal Business Name): GARDENA PHYSICAL THERAPY & REHABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W 155TH STREET SUITE 203
GARDENA CA
90247
US

IV. Provider business mailing address

1300 W 155TH STREET SUITE 203
GARDENA CA
90247
US

V. Phone/Fax

Practice location:
  • Phone: 310-329-1444
  • Fax: 310-329-9586
Mailing address:
  • Phone: 310-329-1444
  • Fax: 310-329-9586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberW19976
License Number StateCA

VIII. Authorized Official

Name: MR. ALAN DAVID NITAKE
Title or Position: PT OWNER
Credential: PT
Phone: 310-329-1444