Healthcare Provider Details

I. General information

NPI: 1952650475
Provider Name (Legal Business Name): RE ACTIVE PHYSICAL THERAPY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8830 S SEPULVEDA BLVD
LOS ANGELES CA
90045-4833
US

IV. Provider business mailing address

8830 S SEPULVEDA BLVD
LOS ANGELES CA
90045-4833
US

V. Phone/Fax

Practice location:
  • Phone: 310-433-0369
  • Fax: 310-933-4803
Mailing address:
  • Phone: 310-433-0369
  • Fax: 310-933-4803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number27665
License Number StateCA

VIII. Authorized Official

Name: JULIE HERSHBERG
Title or Position: OWNER
Credential:
Phone: 310-433-0369