Healthcare Provider Details

I. General information

NPI: 1679489942
Provider Name (Legal Business Name): KRISTIAN JARED ILUSTRE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6180 BROCKTON AVE STE 101
RIVERSIDE CA
92506-2259
US

IV. Provider business mailing address

6180 BROCKTON AVE STE 101
RIVERSIDE CA
92506-2259
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-6653
  • Fax: 951-275-0149
Mailing address:
  • Phone: 951-781-6653
  • Fax: 951-275-0149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: