Provider Demographics
NPI:1205091956
Name:COMPETITIVE ATHLETE TRAINING ZONE OF BREA
Entity type:Organization
Organization Name:COMPETITIVE ATHLETE TRAINING ZONE OF BREA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOEHLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-917-3555
Mailing Address - Street 1:1500 S ANAHEIM BLVD
Mailing Address - Street 2:140
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6242
Mailing Address - Country:US
Mailing Address - Phone:714-917-3555
Mailing Address - Fax:
Practice Address - Street 1:1500 S ANAHEIM BLVD
Practice Address - Street 2:140
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6242
Practice Address - Country:US
Practice Address - Phone:714-917-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation