Healthcare Provider Details

I. General information

NPI: 1336246750
Provider Name (Legal Business Name): J. GRAY O'BRIEN MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 WILSHIRE BL. STE 102
SANTA MONICA CA
90403
US

IV. Provider business mailing address

917 VENEZIA AVE
VENICE CA
90291-3929
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-6454
  • Fax: 310-828-2001
Mailing address:
  • Phone: 310-305-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT25009
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: