Healthcare Provider Details

I. General information

NPI: 1629580188
Provider Name (Legal Business Name): BEACH FAMILY PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17610 BEACH BLVD
HUNTINGTON BEACH CA
92647-6855
US

IV. Provider business mailing address

4132 DELPHI CIR
HUNTINGTON BEACH CA
92649-2176
US

V. Phone/Fax

Practice location:
  • Phone: 714-580-2778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4551
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number4551
License Number StateCA

VIII. Authorized Official

Name: MICHAEL ANTHONY MCCORMICK
Title or Position: CFO
Credential: NMT
Phone: 714-580-2778