Provider Demographics
NPI:1235290636
Name:S&G SANTOSHA, INC.
Entity Type:Organization
Organization Name:S&G SANTOSHA, INC.
Other - Org Name:STACEY SMITH PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:310-458-0898
Mailing Address - Street 1:1502 MONTANA AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1875
Mailing Address - Country:US
Mailing Address - Phone:310-458-0898
Mailing Address - Fax:310-458-6758
Practice Address - Street 1:1502 MONTANA AVE STE 207
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-1875
Practice Address - Country:US
Practice Address - Phone:310-458-0898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22447225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty