Healthcare Provider Details

I. General information

NPI: 1619779618
Provider Name (Legal Business Name): LANGE SPORTS MEDICINE AND PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 03/27/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11012 VENTURA BLVD
STUDIO CITY CA
91604-3546
US

IV. Provider business mailing address

12605 VENTURA BLVD # 1075
STUDIO CITY CA
91604-2415
US

V. Phone/Fax

Practice location:
  • Phone: 630-723-9949
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: DYLAN LANGE
Title or Position: DOCTOR OF PHYSICAL THERAPY/OWNER
Credential: PT, DPT
Phone: 630-723-9949