Provider Demographics
NPI:1679308852
Name:SOCAL KIDS PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:SOCAL KIDS PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:IANNESSA
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:562-810-3197
Mailing Address - Street 1:5869 E PAGEANTRY ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-3717
Mailing Address - Country:US
Mailing Address - Phone:562-810-3197
Mailing Address - Fax:
Practice Address - Street 1:1945 PALO VERDE AVE STE 204
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-3445
Practice Address - Country:US
Practice Address - Phone:562-247-3467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy