Provider Demographics
NPI:1710150172
Name:SOUTHLAND PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:SOUTHLAND PHYSICAL THERAPY INC
Other - Org Name:EXCEL PHYSICAL THERAPY INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:HYUK
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:949-679-3337
Mailing Address - Street 1:4482 BARRANCA PKWY
Mailing Address - Street 2:SUITE 195
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-7701
Mailing Address - Country:US
Mailing Address - Phone:949-679-3337
Mailing Address - Fax:949-679-3336
Practice Address - Street 1:4482 BARRANCA PKWY STE 195
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4706
Practice Address - Country:US
Practice Address - Phone:949-679-3337
Practice Address - Fax:949-679-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32067225100000X, 225100000X
CAPT24454225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPT370670OtherBLUE SHIELD PIN
CAOPT244540OtherBLUE SHIELD PIN
CA0PT320670OtherBLUE SHIELD PIN
CAOT0015030OtherBLUE SHIELD PIN (SHERYL LEE, OTL)
CAOPT384920OtherBLUE SHIELD PIN (RACHEL LEE, DPT)
CAAR052Medicare PIN