Provider Demographics
NPI:1548293780
Name:OUR LADY OF PROVIDENCE PHYSICAL THERAPY CLINIC
Entity type:Organization
Organization Name:OUR LADY OF PROVIDENCE PHYSICAL THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARCELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAIBES
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:818-506-4119
Mailing Address - Street 1:10843 MAGNOLIA BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-3922
Mailing Address - Country:US
Mailing Address - Phone:818-506-4119
Mailing Address - Fax:818-506-8115
Practice Address - Street 1:10843 MAGNOLIA BLVD STE 2
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-3922
Practice Address - Country:US
Practice Address - Phone:818-506-4119
Practice Address - Fax:818-506-8115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 18580261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ08154ZOtherPHYSICAL THERAPY
CAW16446Medicare ID - Type UnspecifiedPHYSICAL THERAPY