Healthcare Provider Details

I. General information

NPI: 1578795688
Provider Name (Legal Business Name): LIFESPAN PHYSIOTHERAPY STAFFING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2941 4TH AVE
SAN DIEGO CA
92103
US

IV. Provider business mailing address

2941 4TH AVE
SAN DIEGO CA
92103-5901
US

V. Phone/Fax

Practice location:
  • Phone: 619-888-5838
  • Fax: 619-568-3313
Mailing address:
  • Phone: 619-888-5838
  • Fax: 619-568-3313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT34535
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT34535
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. ARMIN SHAVERDIAN
Title or Position: PRESIDENT
Credential:
Phone: 858-412-9349