Healthcare Provider Details

I. General information

NPI: 1619535903
Provider Name (Legal Business Name): FYSIOPT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 JAMBOREE RD STE 117
NEWPORT BEACH CA
92660-3006
US

IV. Provider business mailing address

123 ROADRUNNER
IRVINE CA
92603-0161
US

V. Phone/Fax

Practice location:
  • Phone: 312-339-8339
  • Fax:
Mailing address:
  • Phone: 312-339-8339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: SANJAY K REDDY
Title or Position: PHYSICAL THERAPIST/ OWNER
Credential: PT
Phone: 312-339-8339