Healthcare Provider Details

I. General information

NPI: 1083929111
Provider Name (Legal Business Name): MVP SPORTS TECHNOLOGIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23602 VIA FABRICANTE
MISSION VIEJO CA
92691-3143
US

IV. Provider business mailing address

23602 VIA FABRICANTE
MISSION VIEJO CA
92691-3143
US

V. Phone/Fax

Practice location:
  • Phone: 949-215-8941
  • Fax:
Mailing address:
  • Phone: 949-215-8941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number30062
License Number StateCA

VIII. Authorized Official

Name: LEE CUSI
Title or Position: CFO
Credential:
Phone: 949-215-8941