Provider Demographics
NPI:1073603858
Name:SPORTS INJURY PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:SPORTS INJURY PHYSICAL THERAPY, INC
Other - Org Name:PROFESSIONAL ORTHOPEDIC AND SPORTS CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:626-356-0599
Mailing Address - Street 1:801 S RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3223
Mailing Address - Country:US
Mailing Address - Phone:626-356-0599
Mailing Address - Fax:626-356-0570
Practice Address - Street 1:801 S RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3223
Practice Address - Country:US
Practice Address - Phone:626-356-0599
Practice Address - Fax:626-356-0570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAWPT14957B261QP2000X
CAWPT21776B261QP2000X
CAWPT27120B261QP2000X
CAWPT20125B261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19033Medicare ID - Type UnspecifiedPROVIDER #