Healthcare Provider Details

I. General information

NPI: 1912521642
Provider Name (Legal Business Name): ROSE BOWL AQUATICS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 N ARROYO BLVD
PASADENA CA
91103-3201
US

IV. Provider business mailing address

360 N ARROYO BLVD
PASADENA CA
91103-3201
US

V. Phone/Fax

Practice location:
  • Phone: 626-564-0330
  • Fax:
Mailing address:
  • Phone: 626-564-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMIE ANNE O'CONNOR
Title or Position: DIRECTOR OF THERAPY DEPARTMENT
Credential: PT
Phone: 626-564-0330