Healthcare Provider Details

I. General information

NPI: 1265184592
Provider Name (Legal Business Name): VERT SPORTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 SANTA MONICA BLVD
LOS ANGELES CA
90025-2522
US

IV. Provider business mailing address

12400 SANTA MONICA BLVD
LOS ANGELES CA
90025-2522
US

V. Phone/Fax

Practice location:
  • Phone: 310-264-8385
  • Fax: 310-264-9076
Mailing address:
  • Phone: 310-264-8385
  • Fax: 310-264-9076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: KEVIN THEIS
Title or Position: OWNER
Credential:
Phone: 310-264-8385