Healthcare Provider Details

I. General information

NPI: 1093889438
Provider Name (Legal Business Name): THE INJURY RECOVERY CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2006
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17352 VINEWOOD AVE
TUSTIN CA
92780-2551
US

IV. Provider business mailing address

17352 VINEWOOD AVE
TUSTIN CA
92780-2551
US

V. Phone/Fax

Practice location:
  • Phone: 714-785-6573
  • Fax: 714-730-0369
Mailing address:
  • Phone: 714-785-6573
  • Fax: 714-730-0369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 650
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT 650 1011100308
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 12770
License Number StateCA

VIII. Authorized Official

Name: MICHAEL KOERNER
Title or Position: PRESIDENT
Credential: P.T.
Phone: 714-785-6573