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General NPI Number Information
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NPI Number | 1316103260
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE PHYSICAL THERAPY AND TRAINING CENTER INC
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Dates
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Enumeration Date | 07/30/2008
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Last Update Date | 12/08/2008
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Provider Practice Location Address
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Address Line | 24012 CALLE DE LA PLATA SUITE 200
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City | LAGUNA HILLS
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State | CA
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Zip | 92653-3621
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Country | US
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Telephone | 714-904-2918
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Fax | 714-965-5797
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Provider Business Mailing Address
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Address Line | 24012 CALLE DE LA PLATA SUITE 200
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City | LAGUNA HILLS
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State | CA
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Zip | 92653-3621
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Country | US
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Telephone | 714-904-2918
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Fax | 714-965-5797
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. VICTOR RAMON CARLOS
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Credential | DPT
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Telephone | 714-904-2918
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT1503
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT26966
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License Number State | CA
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