Healthcare Provider Details

I. General information

NPI: 1306410774
Provider Name (Legal Business Name): ERIC MICHAEL HULTQUIST PT, DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6080 CENTER DR FL 6
LOS ANGELES CA
90045-9205
US

IV. Provider business mailing address

PO BOX 1295
VENICE CA
90294-1295
US

V. Phone/Fax

Practice location:
  • Phone: 888-859-0145
  • Fax:
Mailing address:
  • Phone: 888-859-0145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number298913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: