Healthcare Provider Details

I. General information

NPI: 1316970486
Provider Name (Legal Business Name): PACIFIC COAST SPORTS & PHYSICAL THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1177 W SAN CARLOS ST
SAN JOSE CA
95126-3441
US

IV. Provider business mailing address

9362 CROSBY AVE
GARDEN GROVE CA
92844-1507
US

V. Phone/Fax

Practice location:
  • Phone: 714-402-1112
  • Fax: 408-993-0381
Mailing address:
  • Phone: 714-402-1112
  • Fax: 408-993-0381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT21215
License Number StateCA

VIII. Authorized Official

Name: JUSTIN TIEN LE
Title or Position: PRESIDENT
Credential: PT
Phone: 714-402-1112