Healthcare Provider Details

I. General information

NPI: 1578879516
Provider Name (Legal Business Name): ZACHARY DAVID PEVNICK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12655 W JEFFERSON BLVD FL 4
LOS ANGELES CA
90066-7008
US

IV. Provider business mailing address

12655 W JEFFERSON BLVD FL 4
LOS ANGELES CA
90066-7008
US

V. Phone/Fax

Practice location:
  • Phone: 310-907-9215
  • Fax: 310-953-3281
Mailing address:
  • Phone: 310-907-9215
  • Fax: 310-953-3281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number36828
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number36828
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number36828
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number36828
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number36828
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: