=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336334150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL THERAPYWORKS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2007
-----------------------------------------------------
Last Update Date | 09/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 719 SANTA MONICA BLVD
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90401-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-260-9039
-----------------------------------------------------
Fax | 310-260-1091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 719 SANTA MONICA BLVD
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90401-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-260-9039
-----------------------------------------------------
Fax | 310-260-1091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JOHN DRAVILLAS
-----------------------------------------------------
Credential | PT, MTC
-----------------------------------------------------
Telephone | 310-260-9039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------