Healthcare Provider Details

I. General information

NPI: 1083521082
Provider Name (Legal Business Name): RYAN BROOKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 BROADWAY STE G
CHULA VISTA CA
91910-5304
US

IV. Provider business mailing address

4223 UTAH ST
SAN DIEGO CA
92104-1803
US

V. Phone/Fax

Practice location:
  • Phone: 619-425-8212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310846
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: