=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285076265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CPRX, INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2013
-----------------------------------------------------
Last Update Date | 07/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3771 KATELLA AVE SUITE 111
-----------------------------------------------------
City | LOS ALAMITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90720-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-799-4494
-----------------------------------------------------
Fax | 562-280-0304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3662 KATELLA AVE SUITE 105
-----------------------------------------------------
City | LOS ALAMITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90720-3124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-799-4494
-----------------------------------------------------
Fax | 562-280-0304
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEREMY W MATTESON
-----------------------------------------------------
Credential | PT, CSCS
-----------------------------------------------------
Telephone | 562-799-4494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT22434
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------