Provider Demographics
NPI:1902848492
Name:GARDENA PHYSICAL THERAPY & REHABILITATION CENTER
Entity Type:Organization
Organization Name:GARDENA PHYSICAL THERAPY & REHABILITATION CENTER
Other - Org Name:ALAN D NITAKE DBA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:NITAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:310-329-1444
Mailing Address - Street 1:1300 W 155TH STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247
Mailing Address - Country:US
Mailing Address - Phone:310-329-1444
Mailing Address - Fax:310-329-9586
Practice Address - Street 1:1300 W 155TH STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247
Practice Address - Country:US
Practice Address - Phone:310-329-1444
Practice Address - Fax:310-329-9586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW19976261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19976Medicare PIN