Provider Demographics
NPI:1144222308
Name:SPORTS MEDICINE INSTITUTE A PROFESSIONAL PHYSICAL THERAPY CORP
Entity Type:Organization
Organization Name:SPORTS MEDICINE INSTITUTE A PROFESSIONAL PHYSICAL THERAPY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOESEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:714-939-6200
Mailing Address - Street 1:1590 S SINCLAIR ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-5933
Mailing Address - Country:US
Mailing Address - Phone:714-939-6200
Mailing Address - Fax:714-939-6500
Practice Address - Street 1:1590 S SINCLAIR ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-5933
Practice Address - Country:US
Practice Address - Phone:714-939-6200
Practice Address - Fax:714-939-6500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2015-09-18
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
CAW14652Medicare PIN