Provider Demographics
NPI:1215796032
Name:REPLENISH PHYSICAL THERAPY & DANCE PERFORMANCE PC
Entity type:Organization
Organization Name:REPLENISH PHYSICAL THERAPY & DANCE PERFORMANCE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HILARY
Authorized Official - Middle Name:PAIGE GEREAUX
Authorized Official - Last Name:VAN DIXHORN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:310-922-3526
Mailing Address - Street 1:2017 LOMITA BLVD # 512
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25830 OAK ST UNIT 7
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-3121
Practice Address - Country:US
Practice Address - Phone:310-922-3526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty