MEDICARE: SPORTS MEDICINE INSTITUTE A PROFESSIONAL PHYSICAL THERAPY CORP

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1144222308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTS MEDICINE INSTITUTE A PROFESSIONAL PHYSICAL THERAPY CORP

Provider Business Mailing Address
First Line	:	415 W TAFT AVE STE E
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-4249
Country	:	US
Telephone Number	:	714-939-6200
Fax Number	:	714-939-6500

Provider Business Practice Location Address
First Line	:	415 W TAFT AVE STE E
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-4249
Country	:	US
Telephone Number	:	714-939-6200
Fax Number	:	714-939-6500

Authorized Official
Title or Position	:	OWNER PRESIDENT
Name	:	JOAN M BOESEL
Credential	:	DPT
Telephone Number	:	714-939-6200

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	10/01/2024

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