MEDICARE: BAO PHUC NGUYEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	300348	CA

General Provider Information

NPI Number	:	1942879515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAO PHUC NGUYEN

Provider Business Mailing Address
First Line	:	5252 LAUREL ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-4913
Country	:	US
Telephone Number	:	619-632-2476
Fax Number	:

Provider Business Practice Location Address
First Line	:	4541 PHILADELPHIA ST STE C103
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-2250
Country	:	US
Telephone Number	:	909-590-7997
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2021
Last Update Date	:	06/18/2021

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