Provider Demographics
NPI:1740288794
Name:GRAHAM, CHRISTOPHER (PT)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 MARKET ST APT C
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-5317
Mailing Address - Country:US
Mailing Address - Phone:424-252-2916
Mailing Address - Fax:424-253-2916
Practice Address - Street 1:1 LMU DR
Practice Address - Street 2:ATHLETIC DEPARTMENT
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-2650
Practice Address - Country:US
Practice Address - Phone:424-252-9816
Practice Address - Fax:424-253-2916
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15428OtherMEDICARE GROUP ID NUMBER
CAWPT23979AMedicare PIN