Healthcare Provider Details

I. General information

NPI: 1316103260
Provider Name (Legal Business Name): SOUTHSIDE PHYSICAL THERAPY AND TRAINING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 12/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24012 CALLE DE LA PLATA SUITE 200
LAGUNA HILLS CA
92653-3621
US

IV. Provider business mailing address

24012 CALLE DE LA PLATA SUITE 200
LAGUNA HILLS CA
92653-3621
US

V. Phone/Fax

Practice location:
  • Phone: 714-904-2918
  • Fax: 714-965-5797
Mailing address:
  • Phone: 714-904-2918
  • Fax: 714-965-5797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT26966
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT1503
License Number StateCA

VIII. Authorized Official

Name: DR. VICTOR RAMON CARLOS
Title or Position: PRESIDENT
Credential: DPT
Phone: 714-904-2918