Healthcare Provider Details

I. General information

NPI: 1215796032
Provider Name (Legal Business Name): REPLENISH PHYSICAL THERAPY & DANCE PERFORMANCE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2024
Last Update Date: 03/14/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25830 OAK ST UNIT 7
LOMITA CA
90717-3121
US

IV. Provider business mailing address

2017 LOMITA BLVD # 512
LOMITA CA
90717-1701
US

V. Phone/Fax

Practice location:
  • Phone: 310-922-3526
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: HILARY PAIGE GEREAUX VAN DIXHORN
Title or Position: PRESIDENT
Credential: PT, DPT
Phone: 310-922-3526