Healthcare Provider Details

I. General information

NPI: 1013047240
Provider Name (Legal Business Name): SPORTS CONDITIONING AND REHABILITATION OF CALIFORNIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 S TUSTIN ST
ORANGE CA
92866-3426
US

IV. Provider business mailing address

871 S TUSTIN ST
ORANGE CA
92866-3426
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-7227
  • Fax: 714-633-9062
Mailing address:
  • Phone: 714-633-7227
  • Fax: 714-633-9062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BOBBY ISMAIL
Title or Position: PRESIDENT
Credential:
Phone: 209-353-1988