Provider Demographics
NPI:1437681459
Name:REPAIR PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:REPAIR PHYSICAL THERAPY INC.
Other - Org Name:REPAIR SPORTS INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ DPT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUCHAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-721-1082
Mailing Address - Street 1:16561 BOLSA CHICA ST STE 107
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3574
Mailing Address - Country:US
Mailing Address - Phone:714-377-4314
Mailing Address - Fax:
Practice Address - Street 1:20311 SW BIRCH ST STE 150
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1779
Practice Address - Country:US
Practice Address - Phone:949-272-1030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REPAIR PHYSICAL THERAPY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38002225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty