Provider Demographics
NPI:1710939707
Name:CALIFORNIA REHABILITATION & SPORTS THERAPY
Entity Type:Organization
Organization Name:CALIFORNIA REHABILITATION & SPORTS THERAPY
Other - Org Name:PRN ADVANCED PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LASSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-570-0510
Mailing Address - Street 1:200 NEWPORT CENTER DR
Mailing Address - Street 2:#213
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7501
Mailing Address - Country:US
Mailing Address - Phone:949-644-1322
Mailing Address - Fax:949-644-0316
Practice Address - Street 1:11276 5TH ST
Practice Address - Street 2:#400
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0921
Practice Address - Country:US
Practice Address - Phone:909-987-1116
Practice Address - Fax:909-987-0126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 14720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06890ZOtherBLUE SHIELD
CA212237OtherFIRST HEALTH
CAZZZ26370ZMedicare PIN