Provider Demographics
NPI:1770616161
Name:OMEGA SPORTS REHABILITATION, INC.
Entity type:Organization
Organization Name:OMEGA SPORTS REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-358-3631
Mailing Address - Street 1:14901 NATIONAL AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032
Mailing Address - Country:US
Mailing Address - Phone:408-358-3631
Mailing Address - Fax:408-358-4537
Practice Address - Street 1:14901 NATIONAL AVE
Practice Address - Street 2:STE 102
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032
Practice Address - Country:US
Practice Address - Phone:408-358-3631
Practice Address - Fax:408-358-4537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
239059200OtherDEPT OF LABOR WORKERS COM
056715Medicare ID - Type Unspecified