Healthcare Provider Details

I. General information

NPI: 1144557729
Provider Name (Legal Business Name): SPORT CENTRAL OSTEOPATHIC, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 03/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8879 LAUREL CANYON BLVD SUITE C
SUN VALLEY CA
91352-2959
US

IV. Provider business mailing address

14069 MARQUESAS WAY SUITE 216D
MARINA DEL REY CA
90292-6052
US

V. Phone/Fax

Practice location:
  • Phone: 818-252-2000
  • Fax: 818-252-6896
Mailing address:
  • Phone: 310-301-3031
  • Fax: 310-301-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG72600
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG72600
License Number StateCA

VIII. Authorized Official

Name: PAUL M ROBINSON
Title or Position: DIRECTOR
Credential: MD
Phone: 818-955-5112