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General NPI Number Information
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NPI Number | 1750537585
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Entity Type | Organization
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Legal Business Name | PACK PHYSICAL THERAPY
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Dates
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Enumeration Date | 08/12/2008
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Last Update Date | 10/27/2008
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Provider Practice Location Address
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Address Line | 24582 DEL PRADO STE E
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City | DANA POINT
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State | CA
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Zip | 92629-3820
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Country | US
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Telephone | 949-443-0713
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3255
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City | DANA POINT
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State | CA
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Zip | 92629-8255
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Country | US
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Telephone | 949-443-0713
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRODIE JAMES PACK
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Credential |
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Telephone | 949-443-0713
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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 | 28869
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License Number State | CA
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