Provider Demographics
NPI:1184898215
Name:PROSTAR SPORTS TRAINING AND REHABILITATION
Entity type:Organization
Organization Name:PROSTAR SPORTS TRAINING AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:909-861-3511
Mailing Address - Street 1:1370 VALLEY VISTA DR STE 145
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3950
Mailing Address - Country:US
Mailing Address - Phone:909-861-3511
Mailing Address - Fax:909-860-7900
Practice Address - Street 1:1370 VALLEY VISTA DR STE 145
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3950
Practice Address - Country:US
Practice Address - Phone:909-861-3511
Practice Address - Fax:909-860-7900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10462225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty