Healthcare Provider Details

I. General information

NPI: 1588128904
Provider Name (Legal Business Name): REBECCA AUSTEN BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8432 MAGNOLIA AVE
RIVERSIDE CA
92504-3297
US

IV. Provider business mailing address

7911 ARLINGTON AVE APT 244
RIVERSIDE CA
92503-0404
US

V. Phone/Fax

Practice location:
  • Phone: 415-488-7531
  • Fax:
Mailing address:
  • Phone: 415-488-7531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: