Healthcare Provider Details

I. General information

NPI: 1730111089
Provider Name (Legal Business Name): MOORPARK PHYSICAL THERAPY & SPORT REHAB CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 W LOS ANGELES AVE
MOORPARK CA
93021-1709
US

IV. Provider business mailing address

545 W LOS ANGELES AVE
MOORPARK CA
93021-1709
US

V. Phone/Fax

Practice location:
  • Phone: 805-530-3838
  • Fax: 805-530-3832
Mailing address:
  • Phone: 805-530-3838
  • Fax: 805-530-3832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT28530
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT24516
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT28978
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT27148
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT19246
License Number StateCA

VIII. Authorized Official

Name: MR. DAVID MICHAEL FACIANA
Title or Position: OWNER
Credential: PT, OCS, SCS, CSCS
Phone: 805-530-3838