=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396895512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCEAN PHYSICAL THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 02/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 CALLE AMANECER STE 320
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-6278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-366-6785
-----------------------------------------------------
Fax | 949-366-6470
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 CALLE AMANECER STE 320
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-6278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-366-6785
-----------------------------------------------------
Fax | 949-366-6470
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. LISSA TREVINO
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 949-366-6785
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------