Healthcare Provider Details

I. General information

NPI: 1134585151
Provider Name (Legal Business Name): SPRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17922 SAN FERNANDO MISSION BLVD
GRANADA HILLS CA
91344-4043
US

IV. Provider business mailing address

16260 VENTURA BLVD SUITE 600
ENCINO CA
91436-2203
US

V. Phone/Fax

Practice location:
  • Phone: 818-360-1864
  • Fax:
Mailing address:
  • Phone: 818-986-1977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License NumberSP5019
License Number StateCA

VIII. Authorized Official

Name: JACOB COHEN
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 818-986-1977