Healthcare Provider Details

I. General information

NPI: 1538719976
Provider Name (Legal Business Name): NICHOLAS CAO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 E IMPERIAL HWY STE 207
BREA CA
92821-6103
US

IV. Provider business mailing address

1525 W TOSCANINI DR
RANCHO PALOS VERDES CA
90275-1837
US

V. Phone/Fax

Practice location:
  • Phone: 310-808-3753
  • Fax:
Mailing address:
  • Phone: 310-831-0962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA50161
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: