Provider Demographics
NPI:1427932425
Name:SPORT SPECIFIC PHYSICAL THERAPY
Entity type:Organization
Organization Name:SPORT SPECIFIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GUNPYO
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:551-574-1109
Mailing Address - Street 1:775 DAWSON AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-4529
Mailing Address - Country:US
Mailing Address - Phone:551-574-1109
Mailing Address - Fax:
Practice Address - Street 1:775 DAWSON AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-4529
Practice Address - Country:US
Practice Address - Phone:551-574-1109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy