Healthcare Provider Details

I. General information

NPI: 1912108572
Provider Name (Legal Business Name): SPECTRUM THERAPY AND SPORTS PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 TECHNOLOGY DR STE 169
IRVINE CA
92618-2328
US

IV. Provider business mailing address

16 TECHNOLOGY DR STE 169
IRVINE CA
92618-2328
US

V. Phone/Fax

Practice location:
  • Phone: 949-595-0700
  • Fax: 949-595-0797
Mailing address:
  • Phone: 949-595-0700
  • Fax: 949-595-0797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT24951
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT33089
License Number StateCA

VIII. Authorized Official

Name: MR. MARC LARSON
Title or Position: OWNER
Credential: RPT
Phone: 949-595-0700