Provider Demographics
NPI:1346619210
Name:PROSPORT PHYSICAL THERAPY PROFESSIONALS INC
Entity Type:Organization
Organization Name:PROSPORT PHYSICAL THERAPY PROFESSIONALS INC
Other - Org Name:PROSPORT PHYSICAL THERAPY-LAGUNA HILLS, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:ISMAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-353-1988
Mailing Address - Street 1:PO BOX 14155
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-1555
Mailing Address - Country:US
Mailing Address - Phone:714-450-4999
Mailing Address - Fax:714-974-0055
Practice Address - Street 1:23001 DEL LAGO DR
Practice Address - Street 2:SUITE C-1
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1354
Practice Address - Country:US
Practice Address - Phone:949-387-7333
Practice Address - Fax:949-916-7309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2023-12-06
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
CACB247253Medicare UPIN