Healthcare Provider Details

I. General information

NPI: 1689746125
Provider Name (Legal Business Name): FRANK WARREN GUSTAFSON RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45240 CLUB DRIVE
INDIAN WELLS CA
92210
US

IV. Provider business mailing address

45240 CLUB DRIVE
INDIAN WELLS CA
92210
US

V. Phone/Fax

Practice location:
  • Phone: 760-200-3322
  • Fax: 760-200-3323
Mailing address:
  • Phone: 760-200-3322
  • Fax: 760-200-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT14299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: