Healthcare Provider Details

I. General information

NPI: 1902573322
Provider Name (Legal Business Name): DYLAN M KRIVICKAS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 11/10/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25136 HANCOCK AVE STE A
MURRIETA CA
92562-0905
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 951-696-7474
  • Fax: 951-696-7575
Mailing address:
  • Phone: 951-335-9825
  • Fax: 951-666-5096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6027
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number303041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: