Healthcare Provider Details

I. General information

NPI: 1588085625
Provider Name (Legal Business Name): WATER AND SPORTS PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3639 MIDWAY DR B286
SAN DIEGO CA
92110-5254
US

IV. Provider business mailing address

3639 MIDWAY DR B286
SAN DIEGO CA
92110-5254
US

V. Phone/Fax

Practice location:
  • Phone: 858-488-3597
  • Fax: 858-724-1747
Mailing address:
  • Phone: 858-488-3597
  • Fax: 858-724-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT40754
License Number StateCA

VIII. Authorized Official

Name: SOPHIA HAMILTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 858-726-2624