Provider Demographics
NPI:1023311073
Name:RESTORATIVE THERAPY ASSOCIATES
Entity type:Organization
Organization Name:RESTORATIVE THERAPY ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:DECICCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-855-0100
Mailing Address - Street 1:20431 JAMES BAY CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8833
Mailing Address - Country:US
Mailing Address - Phone:949-855-0100
Mailing Address - Fax:949-855-0134
Practice Address - Street 1:20431 JAMES BAY CIR
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-8833
Practice Address - Country:US
Practice Address - Phone:949-855-0100
Practice Address - Fax:949-855-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30301261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy