Provider Demographics
NPI:1366680639
Name:KAISER PERMANENTE
Entity type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:NINNESS-SEVERIOS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:310-913-3969
Mailing Address - Street 1:1708 ESPLANADE APT 10
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5326
Mailing Address - Country:US
Mailing Address - Phone:310-913-3969
Mailing Address - Fax:
Practice Address - Street 1:25825 SOUTH VERMONT AVE.
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710
Practice Address - Country:US
Practice Address - Phone:310-517-4060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35342302R00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization