Healthcare Provider Details

I. General information

NPI: 1548476401
Provider Name (Legal Business Name): SPORTS MEDICINE PHYSICAL THERAPY GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 FOOTHILL BLVD
LA CANADA CA
91011-3429
US

IV. Provider business mailing address

650 FOOTHILL BLVD
LA CANADA CA
91011-3429
US

V. Phone/Fax

Practice location:
  • Phone: 818-952-0906
  • Fax:
Mailing address:
  • Phone: 818-952-0906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT219
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT10483
License Number StateCA

VIII. Authorized Official

Name: MRS. ANN MORI
Title or Position: PRESIDENT
Credential: P.T.
Phone: 818-952-0906