Provider Demographics
NPI:1578514832
Name:LAGUNA BEACH REHAB INC
Entity Type:Organization
Organization Name:LAGUNA BEACH REHAB INC
Other - Org Name:LAGUNA BEACH PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FRACALOSY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:949-499-9559
Mailing Address - Street 1:31852 S. COAST HIGHWAY
Mailing Address - Street 2:STE. 303
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651
Mailing Address - Country:US
Mailing Address - Phone:949-499-9559
Mailing Address - Fax:949-499-1845
Practice Address - Street 1:31852 S. COAST HIGHWAY
Practice Address - Street 2:STE. 303
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651
Practice Address - Country:US
Practice Address - Phone:949-499-9559
Practice Address - Fax:949-499-1845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133949261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19811OtherMEDICARE PTAN