MEDICARE: OVAL PHYSICAL THERAPY AND SPORTS MEDICINE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist

General Provider Information

NPI Number	:	1134706005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OVAL PHYSICAL THERAPY AND SPORTS MEDICINE, INC.

Provider Business Mailing Address
First Line	:	10640 RIVERSIDE DR
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2319
Country	:	US
Telephone Number	:	818-643-0517
Fax Number	:

Provider Business Practice Location Address
First Line	:	10640 RIVERSIDE DR
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2319
Country	:	US
Telephone Number	:	818-643-0517
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PATRICK T FAUCETTE
Credential	:	PT
Telephone Number	:	213-598-5758

Provider Enumeration Date	:	03/26/2021
Last Update Date	:	03/26/2021

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