Healthcare Provider Details

I. General information

NPI: 1144720418
Provider Name (Legal Business Name): WILLIAM DYKENS JR. PTA, CCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2719 LOKER AVE W STE A
CARLSBAD CA
92010-6679
US

IV. Provider business mailing address

1551 UNION ST UNIT 910
SAN DIEGO CA
92101-3445
US

V. Phone/Fax

Practice location:
  • Phone: 760-918-9200
  • Fax: 760-918-9203
Mailing address:
  • Phone: 858-213-7558
  • Fax: 760-918-9203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: