Provider Demographics
NPI:1003034075
Name:TOTAL BODY REHABILITATION, INC.
Entity Type:Organization
Organization Name:TOTAL BODY REHABILITATION, INC.
Other - Org Name:PURE PILATES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:949-249-2456
Mailing Address - Street 1:30301 GOLDEN LANTERN
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5990
Mailing Address - Country:US
Mailing Address - Phone:949-249-2456
Mailing Address - Fax:949-249-2365
Practice Address - Street 1:210 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 3
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7530
Practice Address - Country:US
Practice Address - Phone:949-719-2600
Practice Address - Fax:949-719-2626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24777174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT24777OtherSTATE LICENSE
CAW18612Medicare PIN