Healthcare Provider Details

I. General information

NPI: 1417196817
Provider Name (Legal Business Name): TODD ALAN OPSVIG P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2009
Last Update Date: 02/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S CITRUS AVE
AZUSA CA
91702-5911
US

IV. Provider business mailing address

15307 RIVER ROCK DR
FONTANA CA
92336-5346
US

V. Phone/Fax

Practice location:
  • Phone: 626-339-6514
  • Fax:
Mailing address:
  • Phone: 909-684-1255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: