Provider Demographics
NPI:1902177025
Name:CENTRA PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:CENTRA PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:CENTRA
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:714-731-4668
Mailing Address - Street 1:3002 DOW AVE #114
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7236
Mailing Address - Country:US
Mailing Address - Phone:714-731-4668
Mailing Address - Fax:714-464-4668
Practice Address - Street 1:3002 DOW AVE STE 114
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7247
Practice Address - Country:US
Practice Address - Phone:714-731-4668
Practice Address - Fax:714-464-4668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy