Healthcare Provider Details

I. General information

NPI: 1376932095
Provider Name (Legal Business Name): DEEP BHAVSAR III MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2015
Last Update Date: 01/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 YORBA PL
PLACENTIA CA
92870-3152
US

IV. Provider business mailing address

1075 YORBA PL
PLACENTIA CA
92870-3152
US

V. Phone/Fax

Practice location:
  • Phone: 714-524-3500
  • Fax:
Mailing address:
  • Phone: 714-524-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number060802396
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: