Provider Demographics
NPI:1215434790
Name:ORANGE COAST FYZICAL
Entity type:Organization
Organization Name:ORANGE COAST FYZICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-715-0500
Mailing Address - Street 1:PO BOX 53970
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619-3970
Mailing Address - Country:US
Mailing Address - Phone:949-715-0500
Mailing Address - Fax:949-715-0504
Practice Address - Street 1:24361 EL TORO RD STE 140
Practice Address - Street 2:
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-8898
Practice Address - Country:US
Practice Address - Phone:949-715-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORANGE COAST HEAD AND NECK SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty