Healthcare Provider Details

I. General information

NPI: 1801330022
Provider Name (Legal Business Name): THEODOR LORENZ BOTONES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N STATE COLLEGE BLVD SUITE G
ANAHEIM CA
92806-2913
US

IV. Provider business mailing address

13532 CARAVEL PL
CERRITOS CA
90703-6321
US

V. Phone/Fax

Practice location:
  • Phone: 714-999-6596
  • Fax:
Mailing address:
  • Phone: 562-716-9845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA48378
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: