Provider Demographics
NPI:1942209242
Name:OPTC WESTSIDE INC
Entity Type:Organization
Organization Name:OPTC WESTSIDE INC
Other - Org Name:ORTHOSPORT PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRISTINA
Authorized Official - Middle Name:CARMEN
Authorized Official - Last Name:GABOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-837-9700
Mailing Address - Street 1:3831 HUGHES AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2751
Mailing Address - Country:US
Mailing Address - Phone:310-837-9700
Mailing Address - Fax:310-837-9701
Practice Address - Street 1:3831 HUGHES AVE
Practice Address - Street 2:STE 104
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2751
Practice Address - Country:US
Practice Address - Phone:310-837-9700
Practice Address - Fax:310-837-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2020-08-22
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
CAW18495Medicare ID - Type Unspecified