Healthcare Provider Details

I. General information

NPI: 1134532740
Provider Name (Legal Business Name): PROFESSIONAL SPORTS PHYSIATRISTS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E CHAPEL ST STE. 1
SANTA MARIA CA
93454-4607
US

IV. Provider business mailing address

801 E CHAPEL ST STE. 1
SANTA MARIA CA
93454-4607
US

V. Phone/Fax

Practice location:
  • Phone: 805-928-7361
  • Fax: 805-928-5742
Mailing address:
  • Phone: 805-928-7361
  • Fax: 805-928-5742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: FRANCIS PETER LAGATTUTA
Title or Position: MEDICAL DIRECTOR/OWNER
Credential: M.D.
Phone: 805-928-7361