Provider Demographics
NPI:1811423189
Name:SPORTS REHAB LA
Entity Type:Organization
Organization Name:SPORTS REHAB LA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAZIRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:818-986-1203
Mailing Address - Street 1:16200 VENTURA BLVD
Mailing Address - Street 2:#201
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2205
Mailing Address - Country:US
Mailing Address - Phone:818-986-1203
Mailing Address - Fax:951-272-9924
Practice Address - Street 1:16200 VENTURA BLVD
Practice Address - Street 2:#201
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2205
Practice Address - Country:US
Practice Address - Phone:818-986-1203
Practice Address - Fax:951-272-9924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-05
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111NN1001X, 111NR0200X, 111NR0400X, 111NS0005X, 171100000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
No111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty