Healthcare Provider Details

I. General information

NPI: 1154861482
Provider Name (Legal Business Name): MICHAEL EATON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 LANE AVE STE 201
CHULA VISTA CA
91914-4525
US

IV. Provider business mailing address

885 CANARIOS CT STE 110
CHULA VISTA CA
91910-7877
US

V. Phone/Fax

Practice location:
  • Phone: 619-421-9521
  • Fax:
Mailing address:
  • Phone: 619-656-5102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT292907
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: