Healthcare Provider Details

I. General information

NPI: 1952690901
Provider Name (Legal Business Name): CARY COSTA D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22821 LAKE FOREST DR SUITE 115
LAKE FOREST CA
92630-1606
US

IV. Provider business mailing address

22821 LAKE FOREST DR SUITE 115
LAKE FOREST CA
92630-1606
US

V. Phone/Fax

Practice location:
  • Phone: 949-716-5050
  • Fax: 949-482-2122
Mailing address:
  • Phone: 949-716-5050
  • Fax: 949-482-2122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT37671
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251C2600X
TaxonomyCardiopulmonary Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: