Provider Demographics
NPI:1629083480
Name:SPORTS INDUSTRIAL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SPORTS INDUSTRIAL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:951-360-8333
Mailing Address - Street 1:10427 SAN SEVAINE WAY
Mailing Address - Street 2:STE K
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-1199
Mailing Address - Country:US
Mailing Address - Phone:951-360-8333
Mailing Address - Fax:
Practice Address - Street 1:10427 SAN SEVAINE WAY
Practice Address - Street 2:STE K
Practice Address - City:MIRA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91752-1199
Practice Address - Country:US
Practice Address - Phone:951-360-8333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT8535225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty