Healthcare Provider Details

I. General information

NPI: 1124306048
Provider Name (Legal Business Name): DOUGLAS RYAN ROSENTRATER OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9909 MIRA MESA BLVD STE 120
SAN DIEGO CA
92131-1056
US

IV. Provider business mailing address

540 S ANDREASEN DR STE C
ESCONDIDO CA
92029-1916
US

V. Phone/Fax

Practice location:
  • Phone: 858-693-0436
  • Fax: 858-693-0437
Mailing address:
  • Phone: 760-591-7750
  • Fax: 760-294-9813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3630
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: