Provider Demographics
NPI:1912108572
Name:SPECTRUM THERAPY AND SPORTS PERFORMANCE
Entity Type:Organization
Organization Name:SPECTRUM THERAPY AND SPORTS PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:949-595-0700
Mailing Address - Street 1:16 TECHNOLOGY DR STE 169
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2328
Mailing Address - Country:US
Mailing Address - Phone:949-595-0700
Mailing Address - Fax:949-595-0797
Practice Address - Street 1:16 TECHNOLOGY DR STE 169
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2328
Practice Address - Country:US
Practice Address - Phone:949-595-0700
Practice Address - Fax:949-595-0797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT33089261QP2000X
CAPT24951261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy