Healthcare Provider Details

I. General information

NPI: 1528553864
Provider Name (Legal Business Name): BRENT A TALLEY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 S TUSTIN ST
ORANGE CA
92866-3426
US

IV. Provider business mailing address

871 S TUSTIN ST
ORANGE CA
92866-3426
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-7227
  • Fax:
Mailing address:
  • Phone: 408-841-6777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number294986
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: