Healthcare Provider Details

I. General information

NPI: 1679864797
Provider Name (Legal Business Name): RUBY FAITH OVERTON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2011
Last Update Date: 04/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 EL CAMINO REAL
CARLSBAD CA
92009-1603
US

IV. Provider business mailing address

2360 PASEO DE LAURA UNIT 61
OCEANSIDE CA
92056-3721
US

V. Phone/Fax

Practice location:
  • Phone: 760-476-2900
  • Fax: 760-940-4007
Mailing address:
  • Phone: 714-916-8870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5494
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: