Provider Demographics
NPI:1700032455
Name:SAN PEDRO PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SAN PEDRO PHYSICAL THERAPY
Other - Org Name:MARK PEREZ, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-547-2197
Mailing Address - Street 1:1366 W 7TH ST
Mailing Address - Street 2:SUITE 4-B
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3500
Mailing Address - Country:US
Mailing Address - Phone:310-547-3331
Mailing Address - Fax:
Practice Address - Street 1:1366 W 7TH ST
Practice Address - Street 2:SUITE 4-B
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3500
Practice Address - Country:US
Practice Address - Phone:310-547-2197
Practice Address - Fax:310-547-9532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17929174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17929OtherPHYSICAL THERAPY
CA2838OtherPHYSICAL THERAPY
CAG67514OtherMEDICAL BOARD