Provider Demographics
NPI:1588772792
Name:LAVAYEN PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:LAVAYEN PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ALFRED
Authorized Official - Last Name:LAVAYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT ECS
Authorized Official - Phone:949-367-1088
Mailing Address - Street 1:26691 PLAZA DRIVE
Mailing Address - Street 2:SUITE #205
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691
Mailing Address - Country:US
Mailing Address - Phone:949-367-1088
Mailing Address - Fax:949-367-1042
Practice Address - Street 1:26691 PLAZA DRIVE
Practice Address - Street 2:SUITE #205
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-367-1088
Practice Address - Fax:949-367-1042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT11297Medicare PIN