Healthcare Provider Details

I. General information

NPI: 1366156945
Provider Name (Legal Business Name): PETER MITCHELL PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24301 MCIRLANDS BLVD SUITE T
LAKE FOREST CA
92630
US

IV. Provider business mailing address

72880 FRED WARING DR STE B7
PALM DESERT CA
92260-9375
US

V. Phone/Fax

Practice location:
  • Phone: 949-271-0012
  • Fax: 714-256-0770
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT303395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: