Provider Demographics
NPI:1487826889
Name:SG MIKITA RPT A PHYSICAL THERAPY CORPORATION
Entity Type:Organization
Organization Name:SG MIKITA RPT A PHYSICAL THERAPY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKITA
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:818-368-9484
Mailing Address - Street 1:10718 WHITE OAK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-4628
Mailing Address - Country:US
Mailing Address - Phone:818-368-9484
Mailing Address - Fax:818-368-8054
Practice Address - Street 1:10718 WHITE OAK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-4628
Practice Address - Country:US
Practice Address - Phone:818-368-9484
Practice Address - Fax:818-368-8054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28298261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19143Medicare PIN