Provider Demographics
NPI:1578592424
Name:REDONDO ORTHOPEDIC PHYSICAL THERAPY
Entity Type:Organization
Organization Name:REDONDO ORTHOPEDIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:P
Authorized Official - Last Name:TYSSEE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, ATC
Authorized Official - Phone:310-376-9222
Mailing Address - Street 1:520 N PROSPECT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3033
Mailing Address - Country:US
Mailing Address - Phone:310-376-9222
Mailing Address - Fax:
Practice Address - Street 1:23133 HAWTHORNE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3729
Practice Address - Country:US
Practice Address - Phone:310-321-4056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23254261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16395Medicare PIN