Healthcare Provider Details

I. General information

NPI: 1619278751
Provider Name (Legal Business Name): WEST COAST SPINE AND SPORTS THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2010
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6814 MAGNOLIA AVE
RIVERSIDE CA
92506-2843
US

IV. Provider business mailing address

6814 MAGNOLIA AVE
RIVERSIDE CA
92506-2843
US

V. Phone/Fax

Practice location:
  • Phone: 951-774-0793
  • Fax: 951-774-0783
Mailing address:
  • Phone: 951-774-0793
  • Fax: 951-774-0783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

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