Provider Demographics
| NPI: | 1730588575 |
|---|---|
| Name: | COSTA REHAB AND WELLNESS CLINIC |
| Entity type: | Organization |
| Organization Name: | COSTA REHAB AND WELLNESS CLINIC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | CARY |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | COSTA |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | DPT |
| Authorized Official - Phone: | 971-998-4484 |
| Mailing Address - Street 1: | 22821 LAKE FOREST DR |
| Mailing Address - Street 2: | SUITE 115 |
| Mailing Address - City: | LAKE FOREST |
| Mailing Address - State: | CA |
| Mailing Address - Zip Code: | 92630-1606 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 949-716-5050 |
| Mailing Address - Fax: | 949-482-2122 |
| Practice Address - Street 1: | 22821 LAKE FOREST DR |
| Practice Address - Street 2: | SUITE 115 |
| Practice Address - City: | LAKE FOREST |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 92630-1606 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 949-716-5050 |
| Practice Address - Fax: | 949-482-2122 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2014-08-18 |
| Last Update Date: | 2016-04-14 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| CA | PT37671 | 225100000X, 2251C2600X, 2251E1200X, 2251G0304X, 2251H1200X, 2251N0400X, 2251P0200X, 2251S0007X, 2251X0800X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | Group - Single Specialty |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Single Specialty | |
| No | 2251C2600X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Cardiopulmonary | Group - Single Specialty |
| No | 2251E1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Ergonomics | Group - Single Specialty |
| No | 2251G0304X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | Group - Single Specialty |
| No | 2251H1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | Group - Single Specialty |
| No | 2251N0400X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology | Group - Single Specialty |
| No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Single Specialty |
| No | 2251S0007X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | Group - Single Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CB224544 | Medicare PIN |
