Healthcare Provider Details

I. General information

NPI: 1821429358
Provider Name (Legal Business Name): JON FREDERICO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6860 BROCKTON AVE SUITE 7
RIVERSIDE CA
92506-3821
US

IV. Provider business mailing address

24630 WASHINGTON AVE SUITE 200
MURRIETA CA
92562-6131
US

V. Phone/Fax

Practice location:
  • Phone: 951-534-0600
  • Fax: 951-534-0605
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 NumberPT40724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: