Healthcare Provider Details

I. General information

NPI: 1245847540
Provider Name (Legal Business Name): BESPOKE SAN DIEGO PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2748 ARIANE DR UNIT 141
SAN DIEGO CA
92117-3407
US

IV. Provider business mailing address

2748 ARIANE DR UNIT 141
SAN DIEGO CA
92117-3407
US

V. Phone/Fax

Practice location:
  • Phone: 509-294-5289
  • Fax: 646-358-3443
Mailing address:
  • Phone: 509-294-5289
  • Fax: 646-358-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW GUSKIN
Title or Position: DIRECTOR OF BILLING/COLLECTIONS
Credential:
Phone: 646-596-7427