Healthcare Provider Details

I. General information

NPI: 1144222308
Provider Name (Legal Business Name): SPORTS MEDICINE INSTITUTE A PROFESSIONAL PHYSICAL THERAPY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W TAFT AVE STE E
ORANGE CA
92865-4249
US

IV. Provider business mailing address

415 W TAFT AVE STE E
ORANGE CA
92865-4249
US

V. Phone/Fax

Practice location:
  • Phone: 714-939-6200
  • Fax: 714-939-6500
Mailing address:
  • Phone: 714-939-6200
  • Fax: 714-939-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOAN M BOESEL
Title or Position: OWNER PRESIDENT
Credential: DPT
Phone: 714-939-6200