Healthcare Provider Details

I. General information

NPI: 1609004480
Provider Name (Legal Business Name): PROEDGE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 MAIN ST SUITE C
IRVINE CA
92614-6760
US

IV. Provider business mailing address

P.O. BOX 13144
NEWPORT BEACH CA
92658-5086
US

V. Phone/Fax

Practice location:
  • Phone: 949-679-7755
  • Fax: 949-679-7755
Mailing address:
  • Phone: 949-679-7755
  • Fax: 949-679-7755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number26792
License Number StateCA

VIII. Authorized Official

Name: SARA SOGOL AMOLI
Title or Position: OWNER
Credential: MPT, C.S.C.S
Phone: 949-679-7755