Healthcare Provider Details

I. General information

NPI: 1740657444
Provider Name (Legal Business Name): GRAHAM PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LMU DR ATHLETIC DEPARTMENT
LOS ANGELES CA
90045-2650
US

IV. Provider business mailing address

247 MARKET ST UNIT C
VENICE CA
90291-5317
US

V. Phone/Fax

Practice location:
  • Phone: 310-995-1669
  • Fax:
Mailing address:
  • Phone: 310-490-6811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT23946
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT23979
License Number StateCA

VIII. Authorized Official

Name: CINDY GRAHAM
Title or Position: CFO
Credential: PT
Phone: 310-490-6811