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General NPI Number Information
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NPI Number | 1548293780
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Entity Type | Organization
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Legal Business Name | OUR LADY OF PROVIDENCE PHYSICAL THERAPY CLINIC
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Dates
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Enumeration Date | 07/09/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 10843 MAGNOLIA BLVD STE 2
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91601-3922
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Country | US
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Telephone | 818-506-4119
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Fax | 818-506-8115
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Provider Business Mailing Address
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Address Line | 10843 MAGNOLIA BLVD STE 2
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91601-3922
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Country | US
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Telephone | 818-506-4119
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Fax | 818-506-8115
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Authorized Official
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Title or Position | PRESIDENT/DIRECTOR
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Name | MRS. MARCELLE DEAIBES
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Credential | R.P.T
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Telephone | 818-506-4119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT 18580
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License Number State | CA
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