Healthcare Provider Details

I. General information

NPI: 1205105483
Provider Name (Legal Business Name): THOMAS S MITCHELL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2011
Last Update Date: 12/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S HARBOR BLVD STE. 710
ANAHEIM CA
92805-3733
US

IV. Provider business mailing address

PO BOX 6183
CORONA CA
92878-6183
US

V. Phone/Fax

Practice location:
  • Phone: 800-561-5207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT2383
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: