Provider Demographics
NPI:1699840934
Name:WATER AND SPORTS PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:WATER AND SPORTS PHYSICAL THERAPY, INC
Other - Org Name:MISSION BEACH WATER AND SPORTS PHYSICAL THERAPY, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-288-3597
Mailing Address - Street 1:3639 MIDWAY DR STE B286
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5254
Mailing Address - Country:US
Mailing Address - Phone:858-488-3597
Mailing Address - Fax:858-488-3178
Practice Address - Street 1:2999 MISSION BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-8028
Practice Address - Country:US
Practice Address - Phone:858-488-3597
Practice Address - Fax:858-488-3178
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATER AND SPORTS PHYSICAL THERAPY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27239225100000X
CAPT23900225100000X
CAPT20904225100000X
CA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17206Medicare UPIN