Provider Demographics
NPI:1982126728
Name:SKYFALL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SKYFALL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:KETTERHAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:310-743-6649
Mailing Address - Street 1:PO BOX 491471
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-9471
Mailing Address - Country:US
Mailing Address - Phone:310-743-6649
Mailing Address - Fax:
Practice Address - Street 1:11677 SAN VICENTE BLVD STE 207
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5128
Practice Address - Country:US
Practice Address - Phone:310-743-6649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty