Healthcare Provider Details

I. General information

NPI: 1841856689
Provider Name (Legal Business Name): FOREVER YOUNG PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W COAST HWY STE E
NEWPORT BEACH CA
92663-5000
US

IV. Provider business mailing address

1600 W COAST HWY STE E
NEWPORT BEACH CA
92663-5000
US

V. Phone/Fax

Practice location:
  • Phone: 714-944-3289
  • Fax: 949-333-2962
Mailing address:
  • Phone: 714-944-3289
  • Fax: 949-333-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: NADER THEODORY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 949-272-3325