Healthcare Provider Details

I. General information

NPI: 1578932950
Provider Name (Legal Business Name): GRATTO AQUATIC REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13160 MINDANAO WAY STE. 308
MARINA DEL RAY CA
90292
US

IV. Provider business mailing address

13160 MINDANAO WAY STE. 308
MARINA DEL RAY CA
90292
US

V. Phone/Fax

Practice location:
  • Phone: 310-492-9355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MORRIS SHAPOW
Title or Position: PRESIDENT / OWNER
Credential: DPT, PHD
Phone: 310-492-9355