Healthcare Provider Details

I. General information

NPI: 1285099895
Provider Name (Legal Business Name): PAUL WATTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2015
Last Update Date: 12/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 BASELINE RD
LA VERNE CA
91750-2353
US

IV. Provider business mailing address

233 BASELINE RD
LA VERNE CA
91750-2353
US

V. Phone/Fax

Practice location:
  • Phone: 909-833-2986
  • Fax: 909-833-2998
Mailing address:
  • Phone: 909-833-2986
  • Fax: 909-833-2998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: