Healthcare Provider Details

I. General information

NPI: 1760617781
Provider Name (Legal Business Name): MICHELLE EISENBERG PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4165 VIA CANDIDIZ UNIT 30
SAN DIEGO CA
92130-2189
US

IV. Provider business mailing address

PO BOX 12501
LA JOLLA CA
92039-2501
US

V. Phone/Fax

Practice location:
  • Phone: 858-481-2535
  • Fax: 858-481-2532
Mailing address:
  • Phone: 858-481-2535
  • Fax: 858-481-2532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License NumberPT 14819
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: