Healthcare Provider Details

I. General information

NPI: 1528109360
Provider Name (Legal Business Name): VERT WESTSIDE LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 WILSHIRE BLVD
SANTA MONICA CA
90403-2301
US

IV. Provider business mailing address

3011 WILSHIRE BLVD
SANTA MONICA CA
90403-2301
US

V. Phone/Fax

Practice location:
  • Phone: 310-264-8385
  • Fax: 310-264-9076
Mailing address:
  • Phone: 310-264-8385
  • Fax: 310-264-9076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WALTER KURT THEIS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-264-8385