Healthcare Provider Details

I. General information

NPI: 1073603858
Provider Name (Legal Business Name): SPORTS INJURY PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S RAYMOND AVE
PASADENA CA
91105-3223
US

IV. Provider business mailing address

801 S RAYMOND AVE
PASADENA CA
91105-3223
US

V. Phone/Fax

Practice location:
  • Phone: 626-356-0599
  • Fax: 626-356-0570
Mailing address:
  • Phone: 626-356-0599
  • Fax: 626-356-0570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberWPT21776B
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberWPT27120B
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberWPT20125B
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberWPT14957B
License Number StateCA

VIII. Authorized Official

Name: MR. KEVIN LEE WENTZ
Title or Position: OWNER
Credential: P.T.
Phone: 626-356-0599