MEDICARE: SPORTS INDUSTRIAL PHYSICAL THERAPY

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	PT8535	CA

General Provider Information

NPI Number	:	1629083480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTS INDUSTRIAL PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	10427 SAN SEVAINE WAY
Second Line	:	STE K
City	:	MIRA LOMA
State	:	CA
Zip	:	91752-1199
Country	:	US
Telephone Number	:	951-360-8333
Fax Number	:

Provider Business Practice Location Address
First Line	:	10427 SAN SEVAINE WAY
Second Line	:	STE K
City	:	MIRA LOMA
State	:	CA
Zip	:	91752-1199
Country	:	US
Telephone Number	:	951-360-8333
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LAWRENCE WILLIAM CARTER
Credential	:	P.T.
Telephone Number	:	951-360-8333

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	08/22/2020

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Directions to “SPORTS INDUSTRIAL PHYSICAL THERAPY ” Practice Location

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