Provider Demographics
NPI:1316103260
Name:SOUTHSIDE PHYSICAL THERAPY AND TRAINING CENTER INC
Entity type:Organization
Organization Name:SOUTHSIDE PHYSICAL THERAPY AND TRAINING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:RAMON
Authorized Official - Last Name:CARLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:714-904-2918
Mailing Address - Street 1:24012 CALLE DE LA PLATA
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3621
Mailing Address - Country:US
Mailing Address - Phone:714-904-2918
Mailing Address - Fax:714-965-5797
Practice Address - Street 1:24012 CALLE DE LA PLATA
Practice Address - Street 2:SUITE 200
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3621
Practice Address - Country:US
Practice Address - Phone:714-904-2918
Practice Address - Fax:714-965-5797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT1503225X00000X
CAPT26966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty