Healthcare Provider Details

I. General information

NPI: 1104423052
Provider Name (Legal Business Name): PREHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10405 SD MSSN RD STE 103105
SAN DIEGO CA
92108-2102
US

IV. Provider business mailing address

10405 SD MSSN RD STE 103105
SAN DIEGO CA
92108-2102
US

V. Phone/Fax

Practice location:
  • Phone: 646-403-6388
  • Fax:
Mailing address:
  • Phone: 619-369-9442
  • Fax: 213-336-3026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: ALEX GOMETZ
Title or Position: OWNER
Credential: PT
Phone: 212-717-8330