Healthcare Provider Details

I. General information

NPI: 1053318337
Provider Name (Legal Business Name): CENTURY CITY PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK E SUITE 410
LOS ANGELES CA
90067-2001
US

IV. Provider business mailing address

2080 CENTURY PARK E SUITE 410
LOS ANGELES CA
90067-2001
US

V. Phone/Fax

Practice location:
  • Phone: 310-553-2519
  • Fax: 310-553-5842
Mailing address:
  • Phone: 310-553-2519
  • Fax: 310-553-5842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberW14533
License Number StateCA

VIII. Authorized Official

Name: SUSAN BASS
Title or Position: OWNER
Credential: R.P.T.
Phone: 310-553-2519