Healthcare Provider Details

I. General information

NPI: 1265955025
Provider Name (Legal Business Name): THINH TRUONG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5454 EL CAJON BLVD
SAN DIEGO CA
92115-3621
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2400
  • Fax: 619-795-2756
Mailing address:
  • Phone: 619-515-2300
  • Fax: 619-237-1856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13842-24
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number302329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: