Healthcare Provider Details

I. General information

NPI: 1528310547
Provider Name (Legal Business Name): LISA MARIE HARDIMON MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE VINCENT MPT

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 MANHATTAN BEACH BLVD
REDONDO BEACH CA
90278-1604
US

IV. Provider business mailing address

2621 MANHATTAN BEACH BLVD
REDONDO BEACH CA
90278-1604
US

V. Phone/Fax

Practice location:
  • Phone: 310-374-0477
  • Fax: 310-374-1605
Mailing address:
  • Phone: 310-374-0477
  • Fax: 310-374-1605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT19902
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: