=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558513010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALIFORNIA AQUATIC THERAPY & WELLNESS CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2008
-----------------------------------------------------
Last Update Date | 06/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6801 LONG BEACH BOULEVARD
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-537-2224
-----------------------------------------------------
Fax | 310-537-2255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6801 LONG BEACH BOULEVARD
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-537-2224
-----------------------------------------------------
Fax | 310-537-2255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. PATRICIA G DIXON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-293-7335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | PT6921
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------