MEDICARE: WEST COAST SPINE AND SPORTS THERAPY CENTER

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	261QR0400X	Rehabilitation Clinic/Center
2	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1619278751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST COAST SPINE AND SPORTS THERAPY CENTER

Provider Business Mailing Address
First Line	:	6814 MAGNOLIA AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-2843
Country	:	US
Telephone Number	:	951-774-0793
Fax Number	:	951-774-0783

Provider Business Practice Location Address
First Line	:	6814 MAGNOLIA AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-2843
Country	:	US
Telephone Number	:	951-774-0793
Fax Number	:	951-774-0783

Authorized Official
Title or Position	:	DIRECTOR
Name	:	NANCY D KISHINO
Credential	:	OT
Telephone Number	:	951-653-4480

Provider Enumeration Date	:	11/05/2010
Last Update Date	:	11/05/2010

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