Healthcare Provider Details

I. General information

NPI: 1427932425
Provider Name (Legal Business Name): SPORT SPECIFIC PHYSICAL THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 09/20/2025
Certification Date: 09/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 DAWSON AVE
LONG BEACH CA
90804-4529
US

IV. Provider business mailing address

775 DAWSON AVE
LONG BEACH CA
90804-4529
US

V. Phone/Fax

Practice location:
  • Phone: 551-574-1109
  • Fax:
Mailing address:
  • Phone: 551-574-1109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GUNPYO KIM
Title or Position: CEO
Credential:
Phone: 551-574-1109