Healthcare Provider Details

I. General information

NPI: 1235645169
Provider Name (Legal Business Name): MELISSA ETHERTON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 10TH ST
RIVERSIDE CA
92501-3522
US

IV. Provider business mailing address

3908 10TH ST
RIVERSIDE CA
92501-3522
US

V. Phone/Fax

Practice location:
  • Phone: 951-274-7744
  • Fax: 951-274-7754
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT294003
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: