Healthcare Provider Details

I. General information

NPI: 1790334878
Provider Name (Legal Business Name): FYZIOGYM PHYSICAL THERAPY OF CALIFORNIA CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16331 GOTHARD ST
HUNTINGTON BEACH CA
92647-3664
US

IV. Provider business mailing address

711 PACIFIC COAST HWY UNIT 323
HUNTINGTON BEACH CA
92648-5053
US

V. Phone/Fax

Practice location:
  • Phone: 714-690-0385
  • Fax:
Mailing address:
  • Phone: 814-881-4717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LYNEIL MITCHELL
Title or Position: OWNER
Credential: PT
Phone: 814-881-4717