Provider Demographics
NPI:1033413463
Name:CAPOZZOLA, RENEE GRINNELL (MPT)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:GRINNELL
Last Name:CAPOZZOLA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 11TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3938
Mailing Address - Country:US
Mailing Address - Phone:310-210-6374
Mailing Address - Fax:
Practice Address - Street 1:1 CIVIC PLAZA DR
Practice Address - Street 2:SUITE # 625
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2243
Practice Address - Country:US
Practice Address - Phone:310-549-4500
Practice Address - Fax:310-549-4700
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist