Provider Demographics
NPI:1558406728
Name:ADVANCED SPORTS MEDICINE & ORTHOPEDIC PT
Entity Type:Organization
Organization Name:ADVANCED SPORTS MEDICINE & ORTHOPEDIC PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-416-9793
Mailing Address - Street 1:1200 ROSECRANS AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2451
Mailing Address - Country:US
Mailing Address - Phone:310-416-9700
Mailing Address - Fax:310-416-1120
Practice Address - Street 1:1200 ROSECRANS AVE STE 206
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2451
Practice Address - Country:US
Practice Address - Phone:310-416-9700
Practice Address - Fax:310-416-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT188902251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT18890OtherLICENSE
CAW18325Medicare ID - Type Unspecified