=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871751099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENIORS' CHOICE PHYSICAL THERAPY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2008
-----------------------------------------------------
Last Update Date | 07/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1661 GOLDEN RAIN RD BLDG D SUITE 401
-----------------------------------------------------
City | SEAL BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90740-4907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-799-4494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1661 GOLDEN RAIN RD BLDG D SUITE 401
-----------------------------------------------------
City | SEAL BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90740-4907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-799-4494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | JEREMY WILLIAM MATTESON
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 562-799-4494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------