Healthcare Provider Details

I. General information

NPI: 1639272511
Provider Name (Legal Business Name): OWEN MEL CASEM BRUAN RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BROADWAY SUITE 303
CHULA VISTA CA
91911
US

IV. Provider business mailing address

7463 GAYNESWOOD WAY
SAN DIEGO CA
92139-3939
US

V. Phone/Fax

Practice location:
  • Phone: 619-425-8172
  • Fax: 619-425-8337
Mailing address:
  • Phone: 619-708-6322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT28716
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT28716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: