Healthcare Provider Details

I. General information

NPI: 1790746659
Provider Name (Legal Business Name): BRIAN JON ANDERSON MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10020 INDIANA AVE STE. 4
RIVERSIDE CA
92503-5477
US

IV. Provider business mailing address

24630 WASHINGTON AVE STE. 200
MURRIETA CA
92562-6131
US

V. Phone/Fax

Practice location:
  • Phone: 951-637-2320
  • Fax: 951-637-2321
Mailing address:
  • Phone: 951-696-9353
  • Fax: 951-973-7216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-26276
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: