Provider Demographics
NPI:1477651644
Name:OBORN TRACHTMAN & ASTON PHYSICAL THERAPY SPORTS REHABILITATION CENTER
Entity Type:Organization
Organization Name:OBORN TRACHTMAN & ASTON PHYSICAL THERAPY SPORTS REHABILITATION CENTER
Other - Org Name:OTA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:TRACHTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:714-993-3222
Mailing Address - Street 1:PO BOX 5507
Mailing Address - Street 2:OBORN TRACHTMAN ASTON PHYSICAL THERAPY
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92838
Mailing Address - Country:US
Mailing Address - Phone:714-993-3222
Mailing Address - Fax:714-993-6956
Practice Address - Street 1:1535 DEERPARK DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831
Practice Address - Country:US
Practice Address - Phone:714-993-3222
Practice Address - Fax:714-993-6956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6381225100000X
CAPT11894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT11894Medicare ID - Type Unspecified