Provider Demographics
NPI:1306943683
Name:BIOSPHERE COMPREHENSIVE LONGEVITY CENTER INC.
Entity type:Organization
Organization Name:BIOSPHERE COMPREHENSIVE LONGEVITY CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALO
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:310-378-3456
Mailing Address - Street 1:1009 MONTEREY BLVD
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3783
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23133 HAWTHORNE BLVD
Practice Address - Street 2:#103
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3729
Practice Address - Country:US
Practice Address - Phone:310-378-3456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19593225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT19593OtherPHYSICAL THERAPY LICENSE