Provider Demographics
NPI:1427144377
Name:SUCCESS PHYSICAL THERAPY
Entity type:Organization
Organization Name:SUCCESS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:DR
Authorized Official - First Name:NOELLE
Authorized Official - Middle Name:GILSON
Authorized Official - Last Name:BUDROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:310-325-0800
Mailing Address - Street 1:2842 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-2803
Mailing Address - Country:US
Mailing Address - Phone:310-325-0800
Mailing Address - Fax:310-325-7705
Practice Address - Street 1:2842 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2803
Practice Address - Country:US
Practice Address - Phone:310-325-0800
Practice Address - Fax:310-325-7705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17060261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16657Medicare UPIN