Provider Demographics
NPI:1154369213
Name:COVINA HILLS SPORTS MEDICINE INC
Entity type:Organization
Organization Name:COVINA HILLS SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, OCS
Authorized Official - Phone:909-305-1383
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-0099
Mailing Address - Country:US
Mailing Address - Phone:909-305-1383
Mailing Address - Fax:909-305-1435
Practice Address - Street 1:1335 W CYPRESS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3516
Practice Address - Country:US
Practice Address - Phone:909-305-1383
Practice Address - Fax:909-305-1435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT15235Medicare ID - Type UnspecifiedMEDICARE PHYSICAL THERAPY