=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578795688
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESPAN PHYSIOTHERAPY STAFFING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2009
-----------------------------------------------------
Last Update Date | 04/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2941 4TH AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-888-5838
-----------------------------------------------------
Fax | 619-568-3313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2941 4TH AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-5901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-888-5838
-----------------------------------------------------
Fax | 619-568-3313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ARMIN SHAVERDIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-412-9349
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | PT34535
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT34535
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------