Provider Demographics
NPI:1013047240
Name:SPORTS CONDITIONING AND REHABILITATION OF CALIFORNIA INC
Entity Type:Organization
Organization Name:SPORTS CONDITIONING AND REHABILITATION OF CALIFORNIA INC
Other - Org Name:STAR CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:ISMAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-353-1988
Mailing Address - Street 1:871 S TUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-3426
Mailing Address - Country:US
Mailing Address - Phone:714-633-7227
Mailing Address - Fax:714-633-9062
Practice Address - Street 1:871 S TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-3426
Practice Address - Country:US
Practice Address - Phone:714-633-7227
Practice Address - Fax:714-633-9062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2023-12-06
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
CAPT0175090Medicaid
CA05-6762Medicare ID - Type Unspecified