Healthcare Provider Details

I. General information

NPI: 1619923059
Provider Name (Legal Business Name): CORPUS ART PHYSICAL THERAPY PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11860 WILSHIRE BLVD 100
LOS ANGELES CA
90025-6613
US

IV. Provider business mailing address

11860 WILSHIRE BLVD 100
LOS ANGELES CA
90025-6613
US

V. Phone/Fax

Practice location:
  • Phone: 310-312-1111
  • Fax: 310-312-1139
Mailing address:
  • Phone: 310-312-1111
  • Fax: 310-312-1139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VLADISLAV SHUB
Title or Position: PRESIDENT
Credential: P.T.
Phone: 310-312-1111