=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508018789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CASA COLINA COMPREHENSIVE OUTPATIENT REHABILITATION SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2008
-----------------------------------------------------
Last Update Date | 08/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 E BONITA AVE
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91767-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-596-7733
-----------------------------------------------------
Fax | 909-593-0153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 E BONITA AVE
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91767-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-450-0105
-----------------------------------------------------
Fax | 909-593-0153
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | DR. FELICE L. LOVERSO
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 909-596-7733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------