Healthcare Provider Details

I. General information

NPI: 1598763369
Provider Name (Legal Business Name): SPORTS MEDICINE INSTITUTE SOUTH ORANGE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27184 ORTEGA HWY STE 210
SAN JUAN CAPISTRANO CA
92675-5705
US

IV. Provider business mailing address

1070 N BATAVIA ST #537
ORANGE CA
92867-5598
US

V. Phone/Fax

Practice location:
  • Phone: 949-493-1985
  • Fax: 949-493-4295
Mailing address:
  • Phone: 949-493-1985
  • Fax: 949-493-4295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOAN BOESEL
Title or Position: OWNER
Credential: PT
Phone: 714-939-6200