Provider Demographics
NPI:1871878041
Name:CORE PERFORMANCE PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:CORE PERFORMANCE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-294-7001
Mailing Address - Street 1:11 ALISAL CT
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1850
Mailing Address - Country:US
Mailing Address - Phone:213-925-8143
Mailing Address - Fax:
Practice Address - Street 1:15 CORPORATE PLAZA DR
Practice Address - Street 2:SUITE 130
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7918
Practice Address - Country:US
Practice Address - Phone:213-925-8413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA256142251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty