Provider Demographics
NPI:1730111089
Name:MOORPARK PHYSICAL THERAPY & SPORT REHAB CENTER
Entity Type:Organization
Organization Name:MOORPARK PHYSICAL THERAPY & SPORT REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FACIANA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS, SCS, CSCS
Authorized Official - Phone:805-530-3838
Mailing Address - Street 1:545 W LOS ANGELES AVE
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-1709
Mailing Address - Country:US
Mailing Address - Phone:805-530-3838
Mailing Address - Fax:805-530-3832
Practice Address - Street 1:545 W LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-1709
Practice Address - Country:US
Practice Address - Phone:805-530-3838
Practice Address - Fax:805-530-3832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19246225100000X
CAPT28530225100000X
CAPT24516225100000X
CAPT28978225100000X
CAPT27148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14900Medicare PIN