MEDICARE: ATHLETIC LAB PHYSICAL THERAPY AND PERFORMANCE TRAINING

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1427632751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATHLETIC LAB PHYSICAL THERAPY AND PERFORMANCE TRAINING

Provider Business Mailing Address
First Line	:	1330 STANFORD ST APT F
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90404-2543
Country	:	US
Telephone Number	:	805-878-4046
Fax Number	:

Provider Business Practice Location Address
First Line	:	1454 LINCOLN BLVD
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90401-2733
Country	:	US
Telephone Number	:	805-878-4046
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LAUREN FREITAS
Credential	:	DPT
Telephone Number	:	805-878-4046

Provider Enumeration Date	:	05/12/2021
Last Update Date	:	09/06/2023

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