Healthcare Provider Details

I. General information

NPI: 1093571135
Provider Name (Legal Business Name): BENJAMIN EVAN BRISTOL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15302 EL PRADO RD
CHINO CA
91710-7659
US

IV. Provider business mailing address

3100 CHINO HILLS PKWY UNIT 222
CHINO HILLS CA
91709-4232
US

V. Phone/Fax

Practice location:
  • Phone: 909-393-7222
  • Fax:
Mailing address:
  • Phone: 661-304-5277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number305541
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: