Healthcare Provider Details

I. General information

NPI: 1053000224
Provider Name (Legal Business Name): PRESTON RAY ANGSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

3140 RED HILL AVE STE 225
COSTA MESA CA
92626-3440
US

IV. Provider business mailing address

22132 CAMINITO TASQUILLO
LAGUNA HILLS CA
92653-1182
US

V. Phone/Fax

Practice location:
  • Phone: 714-557-2100
  • Fax: 714-557-2111
Mailing address:
  • Phone: 949-910-5953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number50309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: