Provider Demographics
NPI:1548476401
Name:SPORTS MEDICINE PHYSICAL THERAPY GROUP INC.
Entity type:Organization
Organization Name:SPORTS MEDICINE PHYSICAL THERAPY GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:818-952-0906
Mailing Address - Street 1:650 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-3429
Mailing Address - Country:US
Mailing Address - Phone:818-952-0906
Mailing Address - Fax:
Practice Address - Street 1:650 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-3429
Practice Address - Country:US
Practice Address - Phone:818-952-0906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT219261QP2000X
CAPT10483261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID.
CA=========OtherTAX ID.
CAPT219Medicare ID - Type UnspecifiedMEDICARE ID.