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General NPI Number Information
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NPI Number | 1912108572
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Entity Type | Organization
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Legal Business Name | SPECTRUM THERAPY AND SPORTS PERFORMANCE
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Dates
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Enumeration Date | 05/30/2007
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Last Update Date | 02/13/2008
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Provider Practice Location Address
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Address Line | 16 TECHNOLOGY DR STE 169
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City | IRVINE
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State | CA
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Zip | 92618-2328
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Country | US
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Telephone | 949-595-0700
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Fax | 949-595-0797
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Provider Business Mailing Address
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Address Line | 16 TECHNOLOGY DR STE 169
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City | IRVINE
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State | CA
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Zip | 92618-2328
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Country | US
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Telephone | 949-595-0700
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Fax | 949-595-0797
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Authorized Official
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Title or Position | OWNER
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Name | MR. MARC LARSON
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Credential | RPT
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Telephone | 949-595-0700
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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 | PT24951
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT33089
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License Number State | CA
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