Healthcare Provider Details

I. General information

NPI: 1679308852
Provider Name (Legal Business Name): SOCAL KIDS PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 PALO VERDE AVE STE 204
LONG BEACH CA
90815-3445
US

IV. Provider business mailing address

5869 E PAGEANTRY ST
LONG BEACH CA
90808-3717
US

V. Phone/Fax

Practice location:
  • Phone: 562-247-3467
  • Fax:
Mailing address:
  • Phone: 562-810-3197
  • 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: CAROL IANNESSA
Title or Position: OWNER
Credential: MPT
Phone: 562-810-3197