Basic Information
| Provider Information | |||||||||
| NPI: | 1912436676 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GERVAIS | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 235 | ||||||||
| Address2: | |||||||||
| City: | PALOS VERDES ESTATES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902740235 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2355 CRENSHAW BLVD STE 130 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905013329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105398800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2017 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 60757662 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 295668 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | G8967799 | 01 | WA | MEDICARE | OTHER | 1912436676 | 05 | WA | MEDICAID |