Healthcare Provider Details

I. General information

NPI: 1821215500
Provider Name (Legal Business Name): SUSAN MATTOON HUFFAKER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

11651 HUMMINGBIRD PL
MORENO VALLEY CA
92557-6161
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-2669
  • Fax: 951-358-2697
Mailing address:
  • Phone: 951-924-6861
  • Fax: 951-924-6861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT9459
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: