Healthcare Provider Details

I. General information

NPI: 1780929299
Provider Name (Legal Business Name): SAMUEL RICHARD DI GIOVANNI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 COCHRAN ST STE 109
SIMI VALLEY CA
93065-2265
US

IV. Provider business mailing address

1203 FLYNN RD UNIT 160
CAMARILLO CA
93012-6203
US

V. Phone/Fax

Practice location:
  • Phone: 805-526-2311
  • Fax: 805-526-6608
Mailing address:
  • Phone: 805-804-4168
  • Fax: 805-830-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number25826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: