Provider Demographics
NPI:1144557729
Name:SPORT CENTRAL OSTEOPATHIC, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:SPORT CENTRAL OSTEOPATHIC, A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-955-5112
Mailing Address - Street 1:14069 MARQUESAS WAY
Mailing Address - Street 2:SUITE 216D
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6052
Mailing Address - Country:US
Mailing Address - Phone:310-301-3031
Mailing Address - Fax:310-301-3001
Practice Address - Street 1:8879 LAUREL CANYON BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-2959
Practice Address - Country:US
Practice Address - Phone:818-252-2000
Practice Address - Fax:818-252-6896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2010-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72600208D00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G726000OtherBLUE CROSS BLUE SHIELD