Healthcare Provider Details

I. General information

NPI: 1629392824
Provider Name (Legal Business Name): SIDJONN REGALA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 OCEAN FRONT WALK
SAN DIEGO CA
92109-8729
US

IV. Provider business mailing address

3639 MIDWAY DR STE B286
SAN DIEGO CA
92110-5254
US

V. Phone/Fax

Practice location:
  • Phone: 858-488-3597
  • Fax: 858-746-4041
Mailing address:
  • Phone: 858-488-3597
  • Fax: 858-746-4041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number36615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: