Healthcare Provider Details

I. General information

NPI: 1023196045
Provider Name (Legal Business Name): USA REHAB AND WELLNESS CTR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13428 MAXELLA AVE STE 505
MARINA DEL REY CA
90292-5620
US

IV. Provider business mailing address

13428 MAXELLA AVE STE 505
MARINA DEL REY CA
90292-5620
US

V. Phone/Fax

Practice location:
  • Phone: 310-822-3770
  • Fax: 310-822-3770
Mailing address:
  • Phone: 310-822-3770
  • Fax: 310-822-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number20A81676
License Number StateCA

VIII. Authorized Official

Name: MS. FELICIA THOMAS
Title or Position: BILLING MANAGER
Credential: BILLING SERVICE OWNE
Phone: 858-504-0595