Healthcare Provider Details

I. General information

NPI: 1649593690
Provider Name (Legal Business Name): WALTER K THEIS MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 WILSHIRE BLVD
SANTA MONICA CA
90403-2301
US

IV. Provider business mailing address

15322 ANTIOCH ST #87
PACIFIC PALISADES CA
90272-3603
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 NumberG29942
License Number StateCA

VIII. Authorized Official

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