Provider Demographics
NPI:1346316270
Name:DOWNTOWN WATER AND SPORTS
Entity Type:Organization
Organization Name:DOWNTOWN WATER AND SPORTS
Other - Org Name:WATER & SPORTS PHYSICAL THERAPY, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAHL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDFARB
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:858-488-3597
Mailing Address - Street 1:3639 MIDWAY DR STE B286
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5254
Mailing Address - Country:US
Mailing Address - Phone:858-488-3597
Mailing Address - Fax:858-488-3178
Practice Address - Street 1:120 C AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1979
Practice Address - Country:US
Practice Address - Phone:858-488-3597
Practice Address - Fax:858-488-3178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20904225100000X
CAPT23900225100000X
CAPT27239225100000X
225100000X
CA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17206Medicare ID - Type Unspecified