Healthcare Provider Details

I. General information

NPI: 1972844140
Provider Name (Legal Business Name): FUNCTION FIT REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 05/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5348 CARROLL CANYON RD SUITE 101
SAN DIEGO CA
92121-1733
US

IV. Provider business mailing address

5348 CARROLL CANYON RD SUITE 101
SAN DIEGO CA
92121-1733
US

V. Phone/Fax

Practice location:
  • Phone: 858-202-1546
  • Fax: 858-202-1548
Mailing address:
  • Phone: 858-202-1546
  • Fax: 858-202-1548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberAT8848
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DANNY SONG
Title or Position: REHAB DIRECTOR
Credential: PTA, DC
Phone: 858-202-1546