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General NPI Number Information
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NPI Number | 1225466964
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Entity Type | Organization
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Legal Business Name | MARK ANTHONY SPORTS LLC
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Dates
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Enumeration Date | 10/15/2013
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Last Update Date | 10/15/2013
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Provider Practice Location Address
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Address Line | 112 S CATALINA AVE SUITE 6
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City | REDONDO BEACH
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State | CA
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Zip | 90277-3384
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Country | US
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Telephone | 310-801-8879
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Fax | 866-602-2994
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Provider Business Mailing Address
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Address Line | 112 S CATALINA AVE SUITE 6
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City | REDONDO BEACH
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State | CA
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Zip | 90277-3384
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Country | US
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Telephone | 310-801-8879
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Fax | 866-602-2994
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Authorized Official
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Title or Position | OWNER
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Name | MARK ANTHONY PAYARES
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Credential | DPT
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Telephone | 310-801-8879
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | PT38186
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License Number State | CA
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