Provider Demographics
NPI:1114979119
Name:CALIFORNIA REHABILITATION & SPORTS THERAPY
Entity Type:Organization
Organization Name:CALIFORNIA REHABILITATION & SPORTS THERAPY
Other - Org Name:PRN-CALIFORNIA REHABILITATION & SPORTS THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LASSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-570-0510
Mailing Address - Street 1:5962 LA PLACE CT
Mailing Address - Street 2:STE 170
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-8807
Mailing Address - Country:US
Mailing Address - Phone:800-929-4776
Mailing Address - Fax:760-931-8370
Practice Address - Street 1:79440 CORPORATE CENTER DR
Practice Address - Street 2:#112
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7241
Practice Address - Country:US
Practice Address - Phone:760-777-9701
Practice Address - Fax:760-777-9727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 15311225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05302ZOtherBLUE SHIELD
CA2195851OtherFIRST HEALTH
CA2195851OtherFIRST HEALTH