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General NPI Number Information
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NPI Number | 1659499960
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Entity Type | Organization
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Legal Business Name | SUNDANCE PHYSICAL THERAPY
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 04/02/2015
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Provider Practice Location Address
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Address Line | 2212 PICO BLVD
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City | SANTA MONICA
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State | CA
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Zip | 90405-1720
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Country | US
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Telephone | 310-393-9292
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Fax | 310-393-6693
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Provider Business Mailing Address
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Address Line | 2212 PICO BLVD
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City | SANTA MONICA
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State | CA
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Zip | 90405-1720
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Country | US
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Telephone | 310-393-9292
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Fax | 310-393-6693
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Authorized Official
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Title or Position | PRESIDENT
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Name | MASSOUD MOUSAVI
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Credential | PT, DPT
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Telephone | 310-393-9292
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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 | PT19313
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License Number State | CA
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