Provider Demographics
NPI:1659452829
Name:ADVANCED PHYSICAL THERAPY OF LAGUNA-VIEJO A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY OF LAGUNA-VIEJO A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KONOPASKY
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:949-837-2113
Mailing Address - Street 1:26034 ACERO
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2768
Mailing Address - Country:US
Mailing Address - Phone:949-837-2113
Mailing Address - Fax:949-837-2040
Practice Address - Street 1:26034 ACERO
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2768
Practice Address - Country:US
Practice Address - Phone:949-837-2113
Practice Address - Fax:949-837-2040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15402Medicare ID - Type Unspecified
CAW15402Medicare UPIN