Healthcare Provider Details

I. General information

NPI: 1114356375
Provider Name (Legal Business Name): MARK CORPUZ B.S KINESIOLOGY,CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2464 FENTON PKWY APT 201
SAN DIEGO CA
92108-6705
US

IV. Provider business mailing address

PO BOX 12817
SAN DIEGO CA
92112-3817
US

V. Phone/Fax

Practice location:
  • Phone: 619-263-0239
  • Fax: 619-858-2210
Mailing address:
  • Phone: 619-263-0239
  • Fax: 619-858-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: