Healthcare Provider Details

I. General information

NPI: 1699840934
Provider Name (Legal Business Name): WATER AND SPORTS PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 MISSION BLVD SUITE 101
SAN DIEGO CA
92109-8028
US

IV. Provider business mailing address

3639 MIDWAY DR STE B286
SAN DIEGO CA
92110-5254
US

V. Phone/Fax

Practice location:
  • Phone: 858-488-3597
  • Fax: 858-488-3178
Mailing address:
  • Phone: 858-488-3597
  • Fax: 858-488-3178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT27239
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT20904
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT23900
License Number StateCA

VIII. Authorized Official

Name: SOPHIA HAMILTON
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 858-288-3597