Provider Demographics
NPI:1851844708
Name:REPAIR SPORTS INSTITUTE
Entity Type:Organization
Organization Name:REPAIR SPORTS INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:BEAUCHAMP
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, SCS,CSCS
Authorized Official - Phone:951-699-0303
Mailing Address - Street 1:16561 BOLSA CHICA ST
Mailing Address - Street 2:#107
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3594
Mailing Address - Country:US
Mailing Address - Phone:714-377-4314
Mailing Address - Fax:
Practice Address - Street 1:1500 S ANAHEIM BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6242
Practice Address - Country:US
Practice Address - Phone:714-377-4314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty