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General NPI Number Information
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NPI Number | 1760762785
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Entity Type | Organization
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Legal Business Name | ICHOR SPORTS MEDICINE
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Dates
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Enumeration Date | 08/22/2011
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Last Update Date | 12/28/2016
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Provider Practice Location Address
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Address Line | 38397 INNOVATION CT SUITE 104
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City | MURRIETA
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State | CA
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Zip | 92563-2630
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Country | US
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Telephone | 951-888-2323
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Fax |
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Provider Business Mailing Address
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Address Line | 38397 INNOVATION CT SUITE 104
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City | MURRIETA
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State | CA
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Zip | 92563-2630
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Country | US
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Telephone | 951-888-2323
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Fax |
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Authorized Official
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Title or Position | DIRECTOR SPORTS MEDICINE
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Name | MR. ERIBERTO CASILLAS
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Credential | AT,CSCS
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Telephone | 760-209-4419
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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 |
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License Number State |
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