Provider Demographics
NPI:1225466964
Name:MARK ANTHONY SPORTS LLC
Entity Type:Organization
Organization Name:MARK ANTHONY SPORTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:PAYARES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:310-801-8879
Mailing Address - Street 1:112 S CATALINA AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3384
Mailing Address - Country:US
Mailing Address - Phone:310-801-8879
Mailing Address - Fax:866-602-2994
Practice Address - Street 1:112 S CATALINA AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3384
Practice Address - Country:US
Practice Address - Phone:310-801-8879
Practice Address - Fax:866-602-2994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-15
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT381862251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty