Provider Demographics
NPI:1053667261
Name:VERT SAN FERNANDO VALLEY INC
Entity Type:Organization
Organization Name:VERT SAN FERNANDO VALLEY INC
Other - Org Name:VERT SPORTS THERAPY AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:THEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-344-8378
Mailing Address - Street 1:18420 HART ST
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4317
Mailing Address - Country:US
Mailing Address - Phone:818-344-8378
Mailing Address - Fax:818-344-8377
Practice Address - Street 1:18420 HART ST
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4317
Practice Address - Country:US
Practice Address - Phone:818-344-8378
Practice Address - Fax:818-344-8377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGM538AMedicare PIN