Healthcare Provider Details

I. General information

NPI: 1346750601
Provider Name (Legal Business Name): REVITALIZE REHAB CLUB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3646 LONG BEACH BLVD STE 106
LONG BEACH CA
90807-6025
US

IV. Provider business mailing address

3646 LONG BEACH BLVD STE 106
LONG BEACH CA
90807-6025
US

V. Phone/Fax

Practice location:
  • Phone: 562-548-0876
  • Fax:
Mailing address:
  • Phone: 562-548-0876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number30340
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number30340
License Number StateCA

VIII. Authorized Official

Name: DR. DANH NGO
Title or Position: OWNER, PHYSICAL THERAPIST
Credential: PT DPT OCS SCS
Phone: 562-548-0876