Provider Demographics
NPI:1609004480
Name:PROEDGE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PROEDGE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:SOGOL
Authorized Official - Last Name:AMOLI
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, CSCS
Authorized Official - Phone:949-679-7755
Mailing Address - Street 1:P.O. BOX 13144
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-5086
Mailing Address - Country:US
Mailing Address - Phone:949-679-7755
Mailing Address - Fax:949-679-7755
Practice Address - Street 1:1124 MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6760
Practice Address - Country:US
Practice Address - Phone:949-679-7755
Practice Address - Fax:949-679-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA267922251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty