Provider Demographics
NPI:1194950667
Name:PHYSICAL THERAPY AND SPORTS MEDICINE CENTER
Entity type:Organization
Organization Name:PHYSICAL THERAPY AND SPORTS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-589-0850
Mailing Address - Street 1:5565 GROSSMONT CENTER DRIVE
Mailing Address - Street 2:BLDG. 3 SUITE 461
Mailing Address - City:LA MESA
Mailing Address - State:CALIFORNIA
Mailing Address - Zip Code:91942
Mailing Address - Country:UM
Mailing Address - Phone:619-589-0850
Mailing Address - Fax:619-589-0878
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:BLDG. 3, SUITE 461
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-589-0850
Practice Address - Fax:619-589-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT8986261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy