Healthcare Provider Details

I. General information

NPI: 1609002393
Provider Name (Legal Business Name): MOHAMMED N SEDIQUE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 07/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4341 BIRCH STREET, SUITE #102 SELECTIVE REHAB
NEWPORT BEACH CA
92660
US

IV. Provider business mailing address

4341 BIRCH STREET, SUITE #102 SELECTIVE REHAB
NEWPORT BEACH CA
92660
US

V. Phone/Fax

Practice location:
  • Phone: 949-250-7870
  • Fax: 949-475-1003
Mailing address:
  • Phone: 949-250-7870
  • Fax: 949-475-1003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5525
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5525
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: