Provider Demographics
NPI:1659457364
Name:SOUTHERN CALIFORNIA SPORTS REHAB INC
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA SPORTS REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-863-0022
Mailing Address - Street 1:1809 E DYER ROAD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705
Mailing Address - Country:US
Mailing Address - Phone:949-863-0022
Mailing Address - Fax:949-863-0023
Practice Address - Street 1:2428 GRAND AVENUE
Practice Address - Street 2:SUITE E
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:949-863-0022
Practice Address - Fax:949-863-0023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
W18280AMedicare ID - Type Unspecified