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General NPI Number Information
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NPI Number | 1609058445
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Entity Type | Organization
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Legal Business Name | DACOSTA COLLYMORE
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Dates
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Enumeration Date | 12/04/2007
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Last Update Date | 06/24/2008
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Provider Practice Location Address
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Address Line | 5000 OVERLAND AVE #4
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City | CULVER CITY
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State | CA
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Zip | 90230
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Country | US
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Telephone | 310-836-7650
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Fax | 310-836-7651
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Provider Business Mailing Address
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Address Line | 5000 OVERLAND AVE #4
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City | CULVER CITY
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State | CA
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Zip | 90230
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Country | US
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Telephone | 310-836-7650
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Fax | 310-836-7651
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Authorized Official
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Title or Position | CEO OWNER
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Name | DACOSTA ALONZO COLLYMORE
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Credential | RPT
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Telephone | 310-836-7650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 20709
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License Number State | CA
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