Provider Demographics
NPI:1538166079
Name:PROFORMANCE PHYSICAL THERAPY AND REHABILITATION, INC.
Entity type:Organization
Organization Name:PROFORMANCE PHYSICAL THERAPY AND REHABILITATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:323-655-9055
Mailing Address - Street 1:2309 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2631
Mailing Address - Country:US
Mailing Address - Phone:323-697-4046
Mailing Address - Fax:323-655-9255
Practice Address - Street 1:490 S SAN VICENTE BLVD STE 3
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4132
Practice Address - Country:US
Practice Address - Phone:323-655-9055
Practice Address - Fax:323-655-9255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT215452251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16866Medicare ID - Type UnspecifiedGROUP ID