Healthcare Provider Details

I. General information

NPI: 1063233252
Provider Name (Legal Business Name): DARYL BIBBS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8380 CENTER DR STE E
LA MESA CA
91942-2952
US

IV. Provider business mailing address

8865 JORIS WAY
LA MESA CA
91941-6614
US

V. Phone/Fax

Practice location:
  • Phone: 619-466-6077
  • Fax:
Mailing address:
  • Phone: 619-609-3081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number53617
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: