Healthcare Provider Details

I. General information

NPI: 1093713125
Provider Name (Legal Business Name): SPORTS MEDICINE INSTITUTE - LOS ANGELES A PROF PHYSICAL THERAPY CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 S SEPULVEDA BLVD STE 116
LOS ANGELES CA
90045-4814
US

IV. Provider business mailing address

1590 S SINCLAIR ST C/O SMI
ANAHEIM CA
92806-5933
US

V. Phone/Fax

Practice location:
  • Phone: 714-939-6200
  • Fax: 714-939-6500
Mailing address:
  • Phone: 714-939-6200
  • Fax: 714-939-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CINDY GRAHAM
Title or Position: MANAGER
Credential: PT
Phone: 714-939-6200