Provider Demographics
NPI:1750715116
Name:MAVIS RODE PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:MAVIS RODE PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RODE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:310-397-2740
Mailing Address - Street 1:12425 BROOKLAKE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1807
Mailing Address - Country:US
Mailing Address - Phone:310-397-2740
Mailing Address - Fax:310-397-2740
Practice Address - Street 1:12425 BROOKLAKE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-1807
Practice Address - Country:US
Practice Address - Phone:310-397-2740
Practice Address - Fax:310-397-2740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty