Healthcare Provider Details

I. General information

NPI: 1992887616
Provider Name (Legal Business Name): WEST COAST SPINE RESTORATION CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6177 RIVER CREST DR. #A
RIVERSIDE CA
92507
US

IV. Provider business mailing address

6177 RIVER CREST DR. #A
RIVERSIDE CA
92507
US

V. Phone/Fax

Practice location:
  • Phone: 951-653-4480
  • Fax: 951-653-5051
Mailing address:
  • Phone: 951-653-4480
  • Fax: 951-653-5051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: NANCY KISHINO
Title or Position: DIRECTOR
Credential: OT
Phone: 951-653-4480