Provider Demographics
NPI:1093889438
Name:THE INJURY RECOVERY CENTER INC.
Entity Type:Organization
Organization Name:THE INJURY RECOVERY CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOERNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:714-785-6573
Mailing Address - Street 1:17352 VINEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2551
Mailing Address - Country:US
Mailing Address - Phone:714-785-6573
Mailing Address - Fax:714-730-0369
Practice Address - Street 1:17352 VINEWOOD AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2551
Practice Address - Country:US
Practice Address - Phone:714-785-6573
Practice Address - Fax:714-730-0369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-18
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 12770225100000X
CAOT 650225X00000X
CAOT 650 1011100308225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17396Medicare ID - Type Unspecified
CAWPT12770BMedicare ID - Type Unspecified
CAWPT12770AMedicare ID - Type Unspecified
CAW17396AMedicare ID - Type Unspecified