Provider Demographics
NPI:1235266305
Name:COMPREHENSIVE THERAPEUTIC REHABILITATION INC.
Entity Type:Organization
Organization Name:COMPREHENSIVE THERAPEUTIC REHABILITATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-801-9550
Mailing Address - Street 1:655 S FLOWER ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-2805
Mailing Address - Country:US
Mailing Address - Phone:213-430-9180
Mailing Address - Fax:213-430-9193
Practice Address - Street 1:5301 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4038
Practice Address - Country:US
Practice Address - Phone:323-887-7458
Practice Address - Fax:323-887-8288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 11680174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID#