Provider Demographics
NPI:1023569795
Name:SOUTHLAND PHYSICAL THERAPY MISSION VIEJO CLINIC, PC
Entity Type:Organization
Organization Name:SOUTHLAND PHYSICAL THERAPY MISSION VIEJO CLINIC, PC
Other - Org Name:SOUTHLAND PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:MEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:949-627-8800
Mailing Address - Street 1:25565 JERONIMO RD
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2707
Mailing Address - Country:US
Mailing Address - Phone:949-627-8800
Mailing Address - Fax:949-627-8801
Practice Address - Street 1:25565 JERONIMO RD
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2707
Practice Address - Country:US
Practice Address - Phone:949-627-8800
Practice Address - Fax:949-627-8801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHLAND PHYSICAL THERAPY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40531225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty