Provider Demographics
NPI:1902225212
Name:NEW LIGHT PHYSICAL THERAPY AND WELLNESS CENTER INC.
Entity Type:Organization
Organization Name:NEW LIGHT PHYSICAL THERAPY AND WELLNESS CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:ETESSAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:949-878-6792
Mailing Address - Street 1:3 CORPORATE PARK STE 165
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-5161
Mailing Address - Country:US
Mailing Address - Phone:949-878-6792
Mailing Address - Fax:
Practice Address - Street 1:62 CORPORATE PARK
Practice Address - Street 2:SUITE # 235
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-3122
Practice Address - Country:US
Practice Address - Phone:949-878-6792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20329261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1558403733OtherNPI INDIVIDUAL