Provider Demographics
NPI:1821041393
Name:CENTERIMT LOS ANGELES
Entity Type:Organization
Organization Name:CENTERIMT LOS ANGELES
Other - Org Name:CENTERIMT ORANGE COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHISHINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-649-5339
Mailing Address - Street 1:8540 S SEPULVEDA BLVD
Mailing Address - Street 2:STE 702
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3807
Mailing Address - Country:US
Mailing Address - Phone:310-649-5339
Mailing Address - Fax:
Practice Address - Street 1:8540 S SEPULVEDA BLVD
Practice Address - Street 2:STE 702
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3807
Practice Address - Country:US
Practice Address - Phone:310-649-5339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16619AMedicare PIN
CAW16619Medicare PIN