MEDICARE: PROFORMANCE PHYSICAL THERAPY AND REHABILITATION, 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	PT21545	CA

General Provider Information

NPI Number	:	1538166079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFORMANCE PHYSICAL THERAPY AND REHABILITATION, INC.

Provider Business Mailing Address
First Line	:	2309 PACIFIC AVE
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-2631
Country	:	US
Telephone Number	:	323-697-4046
Fax Number	:	323-655-9255

Provider Business Practice Location Address
First Line	:	490 S SAN VICENTE BLVD STE 3
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4132
Country	:	US
Telephone Number	:	323-655-9055
Fax Number	:	323-655-9255

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DONALD E NELSON JR.
Credential	:	PT
Telephone Number	:	323-655-9055

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	08/26/2020

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