Healthcare Provider Details

I. General information

NPI: 1588078653
Provider Name (Legal Business Name): LAURA BUTTRAM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 HARTFIELD AVE
SAN DIEGO CA
92130-1511
US

IV. Provider business mailing address

13101 HARTFIELD AVE
SAN DIEGO CA
92130-1511
US

V. Phone/Fax

Practice location:
  • Phone: 858-259-2222
  • Fax:
Mailing address:
  • Phone: 858-259-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number9539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: