Provider Demographics
NPI:1396799458
Name:MANHATTAN BEACH PACIFIC PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:MANHATTAN BEACH PACIFIC PHYSICAL THERAPY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:P
Authorized Official - Last Name:DEROSA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:310-648-3167
Mailing Address - Street 1:327 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3814
Mailing Address - Country:US
Mailing Address - Phone:310-725-8505
Mailing Address - Fax:310-648-3175
Practice Address - Street 1:327 MAIN ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3814
Practice Address - Country:US
Practice Address - Phone:310-725-8505
Practice Address - Fax:310-648-3175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16147Medicare ID - Type Unspecified