Healthcare Provider Details

I. General information

NPI: 1831426246
Provider Name (Legal Business Name): DENNIS JARDIM PTA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 EL CAMINO REAL SUITE A
CARLSBAD CA
92008-8819
US

IV. Provider business mailing address

5810 EL CAMINO REAL SUITE A
CARLSBAD CA
92008-8819
US

V. Phone/Fax

Practice location:
  • Phone: 760-929-8269
  • Fax:
Mailing address:
  • Phone: 760-929-8269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 6630
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number119702546
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: